Psych CASC / OSCE · Forensic psychiatry — duty to warn and third-party risk
Explain confidentiality limits and protective steps after a threat — CASC communication station
MRCPsych/FRANZCP-style CASC: explain limits of confidentiality, duty to protect principles, minimum disclosure, containment plan, and alliance repair after a third-party threat.
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Target exams
Station brief
Format. Communication station, approximately 7–10 minutes active time after reading. You are the psychiatry registrar. The examiner plays the patient who made a threat. [1]
Candidate instructions. Explain that confidentiality has limits when there is serious risk to others. Cover why you may need to warn the named person and/or involve police or hospital care; what minimum information will be shared; that care continues; and next steps for safety and treatment. Be empathic, non-punitive, clear. Do not invent specific Act section numbers. Check understanding. [3][4][5]
Candidate scenario
The patient says: "I told you I'd hurt my ex because she ruined me. You promised everything stays private. If you call anyone I'll never trust a doctor again. You can't tell her — and don't put me in hospital." There is a clear named target, recent plan, and means. Mental state suggests active psychosis. [1][4]
Marking domains
- Empathy; non-collusion with secrecy that enables harm
- Explains confidentiality limits in plain language
- Links action to safety of identifiable third party and to treating illness
- Describes minimum necessary disclosure (not full file dump)
- Explains possible hospitalisation/containment without invented statutes
- Offers ongoing care and alliance repair
- Checks understanding; invites questions [2][3][5]
Reveal assessor key
Open. Acknowledge anger and fear of exposure; set purpose: keep people safe including him; be honest that some secrets cannot be kept when serious harm is planned. [3]
Explain limits. What you say is usually private. Exception: serious risk of harm to someone else. You named a person and a plan — that engages a duty to protect, not only to listen. [1][4]
What we may do. We may need to tell police and warn her that there is a serious threat, with only the information needed for safety — not your whole life story. We also need to treat your illness and may recommend hospital if community safety cannot be managed. Local legal powers will be used only if needed and as law allows — I will not invent section numbers here; the team follows current local process. [2][5]
Alliance. This is about safety, not punishment. Care continues. Many people still work with their doctor after protective steps if we stay respectful and clear. [2]
Close. Summarise plan; check understanding; answer questions; state immediate next steps. [4]
References
- [1]Appelbaum PS Tarasoff and the clinician: problems in fulfilling the duty to protect Am J Psychiatry, 1985.PMID 3976915
- [2]Binder RL, McNiel DE Application of the Tarasoff ruling and its effect on the victim and the therapeutic relationship Psychiatr Serv, 1996.PMID 8916238
- [3]Appel JM Trends in Confidentiality and Disclosure Focus (Am Psychiatr Publ), 2019.PMID 32047382
- [4]Knoll JL The psychiatrist's duty to protect CNS Spectr, 2015.PMID 25712614
- [5]Bersoff DN Protecting victims of violent patients while protecting confidentiality Am Psychol, 2014.PMID 25046702