Assessment and Management of Patients Who Make Threats Against the President in the Psychiatric Emergency Service

Approximately two years after September 11, 2001, Mr. K, a 26-year-old African-American man, came to the psychiatric emergency service. He had become increasingly angered watching television images of the events of September 11 and blamed President Bush for "getting us into war." Mr. K's girlfriend encouraged him to come to the psychiatric emergency service when he showed her his extensive collection of knives and swords and voiced his desire to "kill the President and 50 white men." On arrival, Mr. K was agitated and suspicious. He was escorted to a secure waiting area where he immediately walked to a corner. He was willing to talk with the non-African American psychiatric resident only when African-American mental health staff were present. Mr. K admitted to his longtime hatred of President Bush. He denied a psychiatric history and denied auditory or visual hallucinations. The urine drug screen was positive for cannabis only.

Mr. K remained agitated and guarded but agreed to take psychotropic medication to calm him down. During his ten hours in the psychiatric emergency service, he repeatedly told the mental health staff—including the security guard, the mental health technician, and the psychiatric resident—that he wanted to kill the President.

The psychiatric resident contacted the Secret Service, who dispatched an agent, accompanied by a local police officer, to the psychiatric emergency service. Upon arrival, this agent presented the agency's Authorization to Review Medical/Psychiatry Files to Mr. K, who agreed to sign it.

After a brief interview, the accompanying police officer filed a petition for involuntary commitment. The Secret Service agent requested that the agency be notified before Mr. K was released and left the psychiatric emergency service. The resident proceeded to civilly commit Mr. K to an inpatient psychiatric hospital to more fully diagnose and treat his psychosis and further evaluate his persistent threats toward the President and others. Mr. K was ultimately given a diagnosis of bipolar disorder and a prescription for psychotropic medications. The Secret Service agent later reassessed Mr. K during the inpatient hospitalization. It was established that Mr. K had a history of repeated threats, a criminal history, and access to weapons. Ultimately, Mr. K was indicted in federal court on violation of the federal threat statute, pled guilty, and was sentenced to five years' probation (2).

Federal law makes it a crime to threaten the President of the United States and authorizes the U.S. Secret Service to protect the President and other protectees (see the two boxes on the next two pages) (3,4). The Secret Service conducts thousands of violence risk assessments each year (5). Such investigations lead to the person's being categorized into one of three classes, as follows.

A majority of the individuals investigated are categorized into class 1, which includes persons who have expressed overt threatening statements but have made no overt action. For example, a person in class 1 might continually call the White House from his living room but does not take any overt action or try to approach the President.

Class 2 comprises individuals who have a history of assaultive behaviors toward authority figures. Such individuals have initiated overt actions such as buying a firearm or traveling to Washington, D.C., to stare at the White House. A person in class 2 exhibits what the Secret Service terms "an unusual direction of interest" in their protectees. Such interest may be evidenced by overzealous activity in political organizations, study of Presidential assassinations, or preoccupation with similar themes (personal communication, Borasi JJ Jr, Special Agent in Charge, Philadelphia Field Office, May 18, 2004).

Individuals in class 3 are considered dangerous and typically have been federally prosecuted under Section 871. These individuals may require lifelong monitoring by the Secret Service. All such individuals are regularly monitored through collateral contacts that may include local law enforcement, family, friends, coworkers, and treatment providers, and status reports—quarterly or monthly depending on the level and current context—are filed. Any changes—moves, arrests, or missed psychiatric appointments—may lead to increased investigation by the Secret Service.

In 1989, Griffith and colleagues (6) addressed the issue of duty to protect the President from threatening patients who have been admitted to inpatient settings. These authors recommended that a senior physician assess the gravity of the patient's statements and share this assessment with hospital administration and attorneys. They recommended several courses of action on the basis of the result on the senior physician's assessment of risk.

Coggins and colleagues (7) surveyed mental health professionals in four states, many of whom worked primarily in outpatient settings. These authors found that most clinicians were unaware of the federal statute regarding threat to the President and did not know the appropriate process and agency to warn when the third party being threatened by a patient is the President. They also found that clinicians used their clinical judgment to assess the seriousness of a threat to the President. If the clinician judged the threat to be nonexistent, no further action was taken. Coggins reiterated the position of the Secret Service: Report "any and all threats so that the appropriate risk assessment and case management can be initiated." This position conflicted with Griffith's earlier guidelines proposing various courses of action based on the "senior physician's assessment."

In considering how to manage patients who threaten the life of the President, we considered various ethical and legal consequences involved in the decision to notify the Secret Service from the psychiatric emergency service. We considered these issues in light of the ethical principles that underlie clinical decision making: beneficence (the physician's duty to provide benefits and balance benefits against risks), autonomy (the physician's respect of the patient as an individual free to choose), nonmaleficience (the physician's oath to do no harm), fidelity (the physician's responsibility to the patient), and justice (the physician's treatment of all patients with equal respect, dignity, and fairness in the distribution of benefits and risks).

With regard to the principle of justice, we considered the question of whether the President's life is more valuable than that of the average citizen being threatened by a patient. The U.S. President is the highest-profile elected official in the country and perhaps the world, elected to make decisions that affect the lives of nearly 295 million U.S. citizens. Certainly if a patient threatens to kill his wife, the threat would, under the justice principle, be taken just as seriously and warrants disclosure or other protective course of action, such as civil commitment. Law enforcement may be contacted to protect the patient's wife, but no specialized agency exists to determine the level of threat. Nor does a specific agency exist to protect her life.

In considering clinicians' fiduciary duty to act in the best interest of the patient, violation of confidentiality, loss of freedom, stigma of federal prosecution, and ongoing Secret Service surveillance are all potential patient consequences. Here the American Medical Association's code of medical ethics regarding the violation of confidentiality is relevant: "The obligation to safeguard patient confidences is subject to certain exceptions which are ethically and legally justified because of overriding social considerations. Where a patient threatens to inflict serious bodily harm to another person or to him or herself and there is a reasonable probability that the patient may carry out the threat, the physician should take reasonable precautions for the protection of the intended victim, including notification of law enforcement authorities" (8).

Because it was not possible to assess the "reasonable probability that the patient may carry out the threat" in the presented case, we determined that "reasonable precautions" included contacting the Secret Service. In contacting the Secret Service, the resident recognized her own limitations in fully assessing the patient's risk. The Secret Service has access to accurate criminal histories that enable the agency to more thoroughly investigate threats. In the case we present here, the patient had a legal history, possessed weapons, and had voiced threats toward the President on many previous occasions. None of this information was known, and nor could the resident on call have discovered it.

We further determined that it is not necessarily in the patient's best interest to minimize his threatening verbalizations toward the President. Autonomous adults take full responsibility for their actions, and there are consequences to violating this federal statute. We also considered that it may be in the best interest of the patient to contact the Secret Service, because it adds protection from the patient's acting in a manner that could lead to serious consequences for the President, millions of American lives, and the patient him- or herself. Notifying the Secret Service does not mean automatic prosecution, nor does it mean lifelong monitoring. The Secret Service interviews the individual, conducts a risk assessment, categorizes the person, and comes to a conclusion as to how to proceed.

We also considered the liability of physicians for both warning and not warning. First, the wording of 18 U.S.C. § 871 does not impose a duty on a psychiatrist to disclose threats to the President to the appropriate authorities. We found no case law imposing such a duty except in the context of the well-established duty to warn or protect third parties (9,10).

The Tenth Circuit did not require a psychotherapist to testify in relation to his or her patient's threats to the President, implying that there may not be an absolute duty to disclose such threats (11). We did not find any cases in which a psychiatrist was prosecuted or reprimanded by federal authorities for failure to disclose a threat.

In a private malpractice nongovernmental action following John Hinckley's March 1981 presidential assassination attempt, victims (excluding President Reagan) sued Hinckley's psychiatrist for failure to warn or protect (12). Dr. Hopper, who had seen Hinckley from late October 1980 until March 1981, was found not to have had a legal duty to protect the plaintiffs from the specific harm.

We found no cases of anyone bringing suit against a psychiatrist for breaching his or her confidentiality about a threat against the President.

We considered the unique characteristics of the psychiatric emergency service when deciding the best course of action in terms of notification of the Secret Service. In many urban university-based settings, the psychiatric emergency service serves as a triage area and a quasi-inpatient setting as well as the entry point for psychiatric hospitalization. Patients who present to the emergency service commonly are acutely psychotic and potentially dangerous and are often diagnostically complicated because of substance use (13,14,15). Their length of stay is highly variable. Often patients need to wait in this setting for inpatient placements.

A patient verbalizing threats against the U.S. President in a psychiatric emergency service is likely to be mentally ill and to require hospitalization. Of the approximately 100 cases investigated monthly by region 1 of the Secret Service (the busiest region, including much of the Eastern Seaboard and the Washington D.C. field office), approximately 50 percent of persons who are ultimately categorized are mentally ill or have a history of mental illness (personal communication, Borasi JJ Jr, Special Agent in Charge, Philadelphia Field Office, May 18, 2004). The hospitalization approach offers several benefits to the patient. First, the patient can be temporarily prevented from carrying out the threat by virtue of confinement in a secure inpatient psychiatric setting. In such a situation there would be no imminent reason, clinically or legally, to inform the Secret Service from the psychiatric emergency service; reporting can be postponed in the event of hospitalization. A second benefit of hospitalization is the stabilizing function of the inpatient unit, where the patient can receive medication.

Several situations may warrant immediate notification of the Secret Service from the psychiatric emergency service. One such situation is patient elopement, either directly from the psychiatric emergency service, en route to an inpatient hospitalization, or upon arrival at the recipient hospital. If the patient is to be transported to another institution for hospitalization, elopement precautions should be taken, including adequate psychotropic medication to target symptoms of psychosis or psychotic agitation and restraint if absolutely necessary for safe transport to prevent harm to the patient and potential harm to others.

A second scenario that necessitates notification from the psychiatric emergency service is a patient who is intoxicated (alcohol, illicit drugs, or, more commonly, some combination) and who comes to the psychiatric emergency service making threats against the President. Because substance use disorders are a major risk factor for violence, we recommend that the Secret Service be contacted if a patient verbalizes threats against the life of the President when intoxicated (16,17,18). Contacting the Secret Service the next day after an intoxicated threatener sobers up makes clinical sense, because it is a rare enough statement that it is notable and should not be easily dismissed, and the Secret Service has the authority to gain access to the person's actual criminal history, whereas clinicians are restrained by confidentiality and privilege protections from doing so. Clinicians must rely on self-report of criminal, violent, and legal history or the reports from collateral contacts that the patient permits us to contact. A preliminary study shows that patients typically underreport criminal histories and minimize history of violence (19). The inaccuracy of these data further compromise our ability to make good clinical decisions.

Another potential situation in the psychiatric emergency service is a patient with a personality disorder who verbalizes threats against the President. We recommend that if such an individual does not meet criteria for hospitalization, the Secret Service should be notified. Again, clinicians are unable to fully know the frequency, intensity, or history of the threats; whether the individual has a history of violence; and whether the person owns or has access to weapons. When the threatener is reported, the Secret Service can utilize identifying information to run an immediate background check and proceed as it deems appropriate.

When a patient presents to a psychiatric emergency service voicing threats against the President of the United States, a comprehensive evaluation is impractical. Although psychiatric emergency service clinicians perform brief violence risk assessments (suicide risk and risk of violence toward others) on a daily basis to make decisions about need for civil commitment, seldom are these evaluations conducted in a comprehensive manner—for example, with actuarial tools. The patient who voices threats against the President of the United States forces clinicians who work in such settings to determine how best to balance the duty to preserve patients' confidentiality with the statutory obligations and duty to warn or protect third parties. Threats to the President are Tarasoff cases involving a duty to warn or protect, except that the President of the United States is the innocent third party, and a specific governmental agency exists to protect his life.

The Secret Service has access to accurate criminal histories and has developed a level of expertise in systematic violence risk assessment that is unmatched by the average clinician working in a psychiatric emergency service setting, who rarely has the opportunity to evaluate such threats. No federal Tarasoff statute exists that defines the magnitude or imminence of threats or that provides immunity to clinicians who report threats against the President or other Secret Service protectees. Given the high profile of the threatened party, we recommend a lower threshold for contacting the Secret Service from a psychiatric emergency service than that often defined by state law for patients who are not admitted to the hospital and other patients described above.

In the psychiatric emergency service, daily interactions occur among patients, mental health clinicians, and law enforcement agencies. Such interactions are fraught with competing interests in terms of patient care, confidentiality, and safety. Questions of whether clinicians who work in psychiatric emergency settings should have access to patients' current legal or criminal status have become more crucial given what appears to be an increased flow of individuals between mental health systems and forensic settings. And if clinicians have access and learn of such information, the question of how these data should be incorporated into clinical decision making and communication with law enforcement requires further investigation.

Dr. Zitek and Dr. Dubin are affiliated with the psychiatry department of Temple University in Philadelphia. Dr. Lewis is a graduate of the Temple University psychiatry residency program and is now a fellow in geriatric psychiatry at the University of California, San Diego. Mr. O'Donnell is with the legal department of Temple University. Send correspondence to Dr. Zitek at Temple Episcopal Hospital, 100 East Lehigh Avenue, Philadelphia, Pennsylvania 19125 (e-mail, [email protected]).