Court Opinion

ID: 9693359
Source: CourtListenerOpinion
Date Created: 2023-08-25 16:38:39.679846+00
Date Added: 2024-06-11T18:19:45.544122
License: Public Domain

JOHNSON, Judge:
We are asked to decide whether a psychiatrist who treats a child for alleged sexual abuse owes a duty of care to the parents of that child where the psychiatrist negligently diagnoses and treats the child and then, based on that misdiagnosis, subsequently embarks upon a course of action that directly affects both the child and the parents, as the alleged abusers. This is an issue of first impression. We have considered the competing policies involved, the case law of Pennsylvania and other jurisdictions, and the particular circumstances of this case. In doing so, we must conclude that, despite the absence of a psychiatrist-patient relationship between the psychiatrist and parents in this case, the psychiatrist owed them a duty of care because the psychiatrist’s actions extended well-beyond the psychiatric treatment of the child. Further, after reviewing all of the parties’ issues in this cross-appeal, we affirm the judgment in all respects.
Nicole Lynn Althaus was bom on April 10, 1975, to Richard and Renee Althaus (the Althauses), Beginning in 1990, a series of catastrophic illnesses struck the Althaus family when Renee was diagnosed with skin and breast cancer. Richard’s mother was then diagnosed with diabetes and pancreatic cancer, from which she eventually died. As a result, Nicole’s emotional and psychological well-being began to deteriorate.
Nicole confided this information to one of her teachers, Priscilla Zappa, and they became quite close. Zappa assisted Nicole in calling a cancer support hotline to provide Nicole with further emotional support during this time. Nicole then spoke to Connie Lap-pa, who was coincidentally Renee’s counselor in a cancer support group at Magee Women’s Hospital. After several phone conversations, Nicole confided in Lappa that her father had touched her inappropriately. Lappa then reported Nicole’s allegations of abuse to the Allegheny County Children and Youth Services (CYS).
CYS then caused Nicole to be removed from her parents’ home. CYS further referred the matter to the Mt. Lebanon Police Department which arrested Richard Althaus and charged him with sexually abusing Nicole. Subsequently, Dr. Susan Nathan, a clinical psychologist, referred Nicole to Dr. Judith Cohen and the Child and Adolescent Sex Abuse Clinic of the University of Pittsburgh Western Psychiatric Institute and Clinic (WPIC).
At trial, Dr. Cohen testified at length about the clime’s role in treating sexually abused children. Dr. Cohen stated that the clinic was a treatment program and did not provide forensic or investigative evaluations. N.T., December 12, 1994, at 16-18. She further stated that the determination of child abuse was made before the child came for treatment and, to that extent, the clinic relied “on the investigations provided by [CYS] and/or forensic evaluations done by independent evaluators of Family Intervention Center.” Id. at 17-18. In accordance with her practice, Dr. Cohen did not make any determination about the truth of Nicole’s allegations. Instead, Dr. Cohen relied on the conclusions made by CYS and Dr. Nathan that Nicole was sexually abused. Dr. Cohen accepted this determination despite the fact that Dr. Mary Carrasco, a physician who examined Nicole for physical signs of abuse, expressed her concern to Dr. Cohen about some of Nicole’s allegations. Dr. Carrasco informed Dr. Cohen that Nicole had made disturbing allegations for which Dr. Carrasco *1150had found no supporting physical evidence. Dr. Cohen stated that she was not surprised that there was no physical findings since she, too, was somewhat skeptical about Nicole’s allegations regarding ritualistic abuse. Id. at 38. However, Dr. Cohen’s skepticism did not affect her acceptance that Nicole was sexually abused. She also made no independent investigation regarding the reports made by Nicole to other individuals. As a result, Dr. Cohen treated Nicole as though she were suffering from post-traumatic stress disorder and depression secondary to sexual abuse.
As Nicole progressed through therapy, her stories became increasingly outlandish, including not only sexual abuse but also ritualistic torture and the murder of several babies that Nicole claimed to have had via caesarian section. Her allegations of abuse widened to include all members of her immediate family, coworkers of her father, and eventually strangers. Consequently, Richard Althaus was arrested three times and Renee was arrested twice during the course of Nicole’s treatment with Dr. Cohen.
Nevertheless, Dr. Cohen steadfastly refused to evaluate the credibility of Nicole’s statements throughout treatment, despite her awareness of the criminal proceedings against the Althauses and the fact that many of Nicole’s allegations of abuse could not be true. While Dr. Cohen was concerned about these fantastical allegations, Dr. Cohen generally avoided direct confrontation with Nicole because of her concern that Nicole would no longer trust her and because she feared that Nicole would make even more of such allegations.
During Nicole’s treatments, Dr. Cohen refused input from the Althauses, as well as Dr. Alan Axelson, a child psychiatrist retained by the Althauses, and Dr. Hilda Schoor-Ribera, Renee Althaus’s cancer support therapist. Despite Dr. Cohen’s insistence that Nicole’s treatment remained strictly therapeutic, she was actively involved in the criminal proceedings against Nicole’s parents and the continued placement of Nicole in a foster home. At a meeting with members of the police investigation team, Dr. Cohen refused to comment on Nicole’s credibility or to discuss ways to detect if a child has been abused; she further informed the officers that it was their responsibility to determine whether Nicole was abused. N.T., supra, at 76-77.
Yet, Dr. Cohen attended several preliminary hearings related to the criminal proceedings against the Althauses and testified under oath that she believed that Nicole had been abused. Id. at 197. At Juvenile Court, she testified that Nicole’s continued placement in foster care with Zappa was appropriate, despite Dr. Axelson’s concern that Nicole’s relationship with Zappa was unhealthy. N.T., November 22, 1994, at 80-82; December 5, 1994, at 76-77. Dr. Cohen explained her presence at the criminal proceedings stating that therapeutic treatment extended to providing emotional support to Nicole while she testified to matters regarding her abuse despite Dr. Cohen’s knowledge that parts of Nicole’s testimony at these proceedings were untrue. N.T., December 12, 1994, at 72.
When the criminal case against Nicole’s parents came before the Honorable Robert E. Dauer, Judge Dauer ordered, over Dr. Cohen’s objection, an independent psychiatric examination of Nicole. The prosecution and the Althauses’ counsel agreed to retain Dr. Marshall Schecter.
Dr. Schecter retained two additional psychologists, and psychological testing was performed on Nicole, Richard and Renee Al-thaus. Dr. Schecter interviewed Nicole, Richard, Renee, Dr. Cohen and numerous health care professionals who had provided care to Nicole. He spoke to Nicole’s grandmother, her brother, and Renee’s therapist, Dr. Schoor-Ribera. Dr. Schecter reviewed all of Nicole’s scholastic records and writings, and spoke with her at great length. Based on his extensive evaluation of Nicole, Dr. Schecter testified at the hearing that, in his opinion, Nicole suffered from a borderline personality disorder. He stated that he did not believe Nicole was ever abused and that her allegations of abuse stemmed from Nicole’s inability to distinguish fact from fantasy. Dr. Schecter further testified that Ni- ’ cole’s inability to distinguish truth from fantasy rendered her incompetent to testify.
*1151Dr. Cohen also testified at Nicole’s competency hearing. Initially, she stated that, based on her therapeutic treatment of Nicole, she was in a better position than Dr. Schec-ter to assess Nicole’s competence. Id. at 106. During cross-examination, however, Dr. Cohen conceded that many of Nicole’s allegations were untrue, and that, at times, Nicole could not distinguish fact from fantasy. When Judge Dauer informed Dr. Cohen that the ability to distinguish fact from fantasy was a condition precedent to testifying under oath, Dr. Cohen advised Nicole not to testify. Consequently, Nicole did not testify and the Commonwealth withdrew the criminal charges filed against the Althauses.
The Althauses and their daughter Nicole then brought the present negligence action against Dr. Cohen and WPIC, on the theory that Dr. Cohen negligently diagnosed and treated Nicole and that this negligence exacerbated Nicole’s undiagnosed borderline personality disorder. The Althauses farther contended that Dr. Cohen owed them a duty of care because of her awareness that many of Nicole’s allegations could not be true and because of her knowledge that these allegations were the basis of the criminal proceedings against them. The case was submitted to a jury, which returned verdicts in favor of both Nicole and her parents. Both parties filed post-trial motions that the court denied. This appeal by Dr. Cohen and WPIC and cross-appeal by the Althauses and their daughter Nicole followed.
On appeal, Dr. Cohen and WPIC argue that the trial court erred when it (1) held that a psychiatrist treating a child for alleged sexual abuse owes a duty of care to non-patient parents, as the alleged abusers and (2) refused to instruct the jury on both the Althauses’ and their daughter Nicole’s alleged contributory negligence.
In their cross-appeal, the Althauses and their daughter Nicole argue that the trial court erred when it: (1) concluded that the good faith immunity provisions of the child protective services law, 23 Pa.C.S. § 6318, precluded the Althauses from using Dr. Cohen’s testimony from the various legal proceedings for the purpose of supporting their allegations of negligence; (2) precluded the Althauses from submitting testimony relating to the results of Mr. Althaus’s lie detector test and the fact that Dr. Cohen was aware that he had passed it; (3) refused to instruct the jury on the issue of punitive damages; and (4) concluded that Nicole Althaus was not entitled to delay damages.
We first address Dr. Cohen’s and WPIC’s argument that Dr. Cohen owed no duty of care to the Althauses because of the nonexistence of a psychiatrist-patient relationship between them. Initially, we note that while we find no error with the trial court’s imposition of a duty in this instance, we do so because of the particular circumstances of this case. In his Dissenting Opinion, our distinguished colleague, Judge Schiller, seems to pose the issue in a formulation that we are not, here, trying to answer. We do not conclude, as Judge Schiller charges, that a psychiatrist who treats a child for alleged sexual abuse owes an absolute duty of care to the parents of that child for negligent psychiatric treatment of that child. If that were all that happened here, we would not find that Dr. Cohen owed a duty to the Althauses. Dr. Cohen’s conduct, however, extended far beyond the negligent treatment of Nicole Althaus. Here, Dr. Cohen actively participated in the criminal proceedings against the Althauses. She attended several preliminary hearings at Nicole’s request and remained passive as Nicole made outlandish allegations against her parents and others—allegations that Dr. Cohen knew were not true. Though she recognized that, at times, Nicole could not distinguish fact from fantasy, she nonetheless allowed Nicole to testify to these allegations and, in doing so, essentially validated Nicole’s unwittingly false testimony. Accordingly, because Dr. Cohen’s actions extended well-beyond the psychiatric treatment of Nicole, we conclude that Dr. Cohen owed a duty of care to the Althauses and that the lack of a psychiatric-patient relationship does not provide blanket immunity to Dr. Cohen.
Pennsylvania courts have set forth the basic elements of a negligence claim as follows:
1. A duty, or obligation, recognized by the law, requiring the actor to conform to a certain standard of conduct, for *1152the protection of others against unreasonable risks.
2. A failure on [the actor’s] part to conform to the standard required.
3. A reasonably close eausal connection between the conduct and the resulting injury....
4. Actual loss or damage resulting to the interests of another.
Fennell v. Nationwide Mutual Fire Ins., 412 Pa.Super. 534, 539, 603 A.2d 1064, 1066-67 (1992), citing Prosser, Law of Torts, § 30, at 143 (4th ed.1971).
Whether a legal duty exists under a set of facts is a question of law. Huddleston v. Infertility Center of America, Inc., 700 A.2d 453, 457 (Pa.Super.1997). Our duty analysis depends on many factors and is “necessarily rooted in public policy considerations, i.e., our ideas of history, morals, justice, and society in general in determining where the loss should fall.” Gardner v. Consolidated Rail Corp., 524 Pa. 445, 455, 573 A.2d 1016, 1020 (1990); see also Troxel v. A.I. Dupont Institute, 450 Pa.Super. 71, 80-84, 675 A.2d 314, 319-20, appeal denied, 546 Pa. 668, 685 A.2d 547 (1996). Once we determine that a legal duty exists, we impose liability only in those instances where the harmful consequences of the defendant’s conduct could reasonably have been foreseen and prevented by the exercise of reasonable care. Mohler v. Jeke, 407 Pa.Super. 478, 595 A.2d 1247, 1252 (1991).
Our discussion of this issue begins with cases of this Commonwealth involving communicable diseases where both our supreme court and this Court have found physicians liable to individuals outside the physician-patient relationship. DIMarco v. Lynch Homes—Chester County, Inc., 525 Pa. 558, 583 A.2d 422 (1990); Troxel, supra. We find the negligence analysis set forth in these cases applicable to the facts presented before us.
In DiMarco, supra, a hepatitis patient was advised by her physician that she could resume sexual activity in six weeks without fear of infecting her partner. The woman waited eight weeks, but her partner nevertheless contracted hepatitis. Id. at 560, 583 A.2d at 423. Because of the nature of the disease, the court stated that a patient must be advised to take certain precautions. The court noted that such precautions are not for the benefit of the patient; rather, precautions are for the benefit of third parties. Our supreme court, in imposing a duty on the physician to the partner, rejected the notion that the lack of a physician-patient relationship barred a third party from maintaining a cause of action against a professional in instances where the policies limiting a professional’s liability “pale in comparison to the harm at issue.” Id. at 562 n. 1, 583 A.2d at 425 n. 1. Rather:
If a third person is in that class of persons whose health is likely to be threatened by the patient, and if erroneous advice is given to that patient to the ultimate detriment of the third person, the third person has a cause of action against the physician, because the physician should recognize that the services rendered to the patient are necessary for the protection of the third person.
Id. at 562, 583 A.2d at 424-25. See also Troxel, supra (physician who treated mother and child for cytomegalovirus owed duty to third persons to inform patient about contagious nature of disease to prevent its spread to foreseeable persons, which included plaintiff, who had been exposed to virus while pregnant and, as a result, her child had died shortly after birth).
No Pennsylvania appellate court has ever addressed whether a psychiatrist owes a duty of care to a patient’s family where the psychiatrist misdiagnosed the patient as having been sexually abused by a family member. However, the District Court for the Eastern District of Pennsylvania has visited this issue. In Turnan v. Genesis Associates, 894 F.Supp. 183 (E.D.Pa.1995), the parents of an adult child sued their daughter’s therapists on a negligence theory when their daughter falsely stated that the parents had committed incest and murder, and lead a satanie cult. The court eventually dismissed the negligence claim because the parents failed to allege physical injury. Id. at 189. However, the court began its discussion by concluding that the therapist in this instance *1153owed a duty to the patient’s parents. Id. at 188. After reviewing Pennsylvania law, the court stated that “although a plaintiff generally must show a professional relationship to maintain a claim for professional negligence, the absence of such a relationship does not necessarily bar a plaintiff’s recovery where the defendant’s negligence causes substantial harm to an identifiable and readily determinable class of plaintiffs.” Id.
As these cases suggest, the absence of a physician-patient relationship between a plaintiff and a defendant-physician does not bar a cause of action based on negligence. Rather, in determining whether a physician owes a duty to persons outside the physician-patient relationship under a particular set of facts, a court should carefully weigh any policy considerations that might exist and limit liability to those instances where the harmful consequences of the physician’s actions could reasonably have been foreseen and prevented by the exercise of reasonable care. In other words, traditional principles of negligence should be employed to determine whether a physician owes a duty outside of the physician-patient relationship.
Moreover, several cases decided in other jurisdictions recognize such a duty. We are persuaded by the reasoning of the Supreme Court of. New York in Caryl S. v. Child & Adolescent Treatment Services, Inc., 161 Misc.2d 563, 614 N.Y.S.2d 661 (N.Y.Sup.Ct.1994), aff'd, 238 A.D.2d 953, 661 N.Y.S.2d 168 (1997). In that case, the court held that a therapist owed a duty of care to individuals not considered part of the patient-therapist relationship. Following a visit with her grandparents, four-year-old Amanda told her mother, Cheryl, that Caryl, Amanda’s grandmother, placed a stick in her vagina, causing it to bleed. Cheryl took Amanda to the hospital for an examination, but no physical evidence of sexual abuse was observed. Cheryl then related the incident to the police and to the Child Protection Services. Cheryl also called the Child & Adolescent Treatment Services, Inc. (CATS) regarding counseling for Amanda. Id. 614 N.Y.S.2d at 662.
At CATS, Amanda was principally seen by therapist Patricia Jones. Jones testified in Family Court about Amanda’s alleged sexual abuse by Caryl. After interviewing Amanda’s grandparents and determining that Ca-ryl’s portrayal of the events was not credible, Jones recommended to Amanda’s family court guardian that she have only supervised visits with her grandmother until Caryl “exhibit[s] some responsibility for her actions and obtain[s] some counseling for whatever emotional problems she may have.” Id. at 663. Jones was subsequently deposed in the grandparents’ Family Court action to obtain visitation with Amanda, and testified at that trial. Id.
Caryl and her husband petitioned the court to recover for damages for injuries suffered by them as a result of Jones’s acts. In their first cause of action, plaintiffs contended that Jones “ ‘negligently, carelessly and recklessly reached the false conclusion that ... C[aryl] sexually abused A[manda],’ and thereafter negligently, carelessly and recklessly informed others of that conclusion.” Id. at 663. The plaintiffs maintained that a duty to them resulted from “the fact that it was reasonably foreseeable that when [Jones] negligently formed an opinion that Caryl S. had sexually abused her granddaughter Amanda, and when that negligently formed opinion was negligently communicated to others, the relationship between plaintiffs and Amanda would be ‘adversely affect[ed]’ and plaintiffs would be harmed.” Id. at 664.
The court began its inquiry by examining whether the defendants owed a duty to the plaintiffs. It noted that, in recent years, society had made much progress in exposing child abuse, but that, at the same time, efforts to root out child abuse had caused the suffering of many innocent parents. Id. at 665. The court then stated that, given the foregoing considerations:
[I]t should be readily apparent that when a professional becomes involved in a case where child sexual abuse is suspected, care must be taken in investigating and evaluating such a claim and in reaching the conclusion that such abuse did take place. Where the professional is involved in a therapeutic relationship with the child, it requires little imagination to see the harm that might result from a negligently and erroneously formed conclusion that sexual *1154abuse had occurred, with subsequent treatment based on that ‘misdiagnosis.’ In such a situation there would be no dispute that a cause of action for malpractice (or ordinary negligence) would exist on the child’s behalf against the professional....
Id. at 666. The court then addressed what duty a therapist owed to those outside the therapist-patient relationship. In a situation such as the one presented before it, the court stated that:
[A] determination must initially be made by the professional that sexual abuse in fact occurred, and this determination is made not only about the child but also about the suspected abuser. When, based upon that determination, a course of action is thereafter embarked upon by the professional, it is intended to, and necessarily does, affect both the child and his or her abuser, especially where a family relationship is involved. A suspected abuser has the right to a reasonable expectation that such a determination, touching him or her as profoundly as it will, will be carefully made and will not be reached in a negligent maimer.
Id. The court then concluded that a therapist owed a duty to one accused, even if outside the therapy relationship, when the therapist makes the determination of sexual abuse and pursues a course of action aimed at shaping the conduct of both the alleged victim and the accused. Id. at 667. It further noted that such a duty was limited to specifically foreseeable parties. Id.
A similar case was recently decided in California. In James W. v. Superior Court, 17 Cal.App.4th 246, 21 Cal.Rptr.2d 169 (1993), the court concluded that California’s Child Abuse and Neglect Reporting Act did not protect a therapist who was sued by the victim and her family for allegedly abusing the therapeutic relationship and falsely accusing the father of molestation. In James W., eight-year-old Alicia complained of pain when she went to the bathroom one morning. Her family took her to the hospital where the staff determined that she had been raped and sodomized and filed a report pursuant to the Child Abuse and Neglect Reporting Act. Alicia stated that a man had come through her bedroom window and hurt her. However, a hospital staff member and a detective accused Alicia’s father of the rape. Id. at 170-71.
The Department of Social Service placed Alicia in temporary foster care and referred the family to a private family counselor. At the first family session, the counselor accused the father of the abuse. For over a year and a half, however, Alicia insisted that her father was not the assailant. Both her foster parents and the counselor continuously pressured Alicia into stating that her father was the perpetrator. During this time, Alicia was completely cut off from her family despite court ordered weekly visitation because the foster parents and the counselor refused to cooperate. Eventually, coached by her foster parents and the counselor, Alicia testified against her father in court. Alicia’s father was arrested and charged with raping and sodomizing Alicia. Id. at 171-72.
At the same time, Alicia’s foster parents moved to permanently adopt her. In the interim, however, the results of forensic testing showed that Alicia’s father could not have been the perpetrator. Consequently, the adoption proceedings were halted, all charges against the father were dropped, steps were taken to reunite Alicia with her family, and the court removed the counselor as Alicia’s therapist. Id. at 172.
When Alicia’s family subsequently filed a civil complaint against the counselor, the counselor argued that she had immunity under the Child Abuse and Neglect Reporting Act. The court rejected this argument stating that “[t]he Act is a reporting statute and its protection runs to reporting: it does not apply to activities that continue more than two years after the initial report of abuse by parties who are not acting as reporters.” Id. at 174. The court concluded that the Act was satisfied when hospital staff reported the incident. Id.
The court further stated that its distinction between the initial reporters and those who voluntarily assume roles once the report is filed is a “healthy” one:
It discourages family counselors and foster parents from taking on roles they are not *1155adequately prepared to perform. When private citizens become deeply enmeshed in investigatory or prosecutorial activities and take on functions of the police, the [Department of Social Services], county counsel or district attorney, the system suffers a loss of objectivity, independence, balance and accountability. The combination of private players and public officials all on one side performing the same roles, albeit for different reasons, has a momentum of its own which can, in its own way, overwhelm any family.
Id. at 176. The court also concluded that where a counselor abuses “a therapeutic relationship with family members, causing injury to the children, emotional distress to the parent, and disrupting the parent-child relationship, they breach their duties of care to the parent as well as the children and are hable to both.” Id. at 177.
Finally, in Montoya v. Bebensee, 761 P.2d 285 (Colo.Ct.App.1988), the Colorado Court of Appeals reinstated a father’s claim against his daughter’s therapist. With no physical evidence of sexual abuse, therapist Barbara Bebensee, after two perfunctory visits with the daughter, concluded that the daughter had been sexually abused by her father. Her conclusion was contrary to both a social worker’s report of the events related to her by the child, and to the determination made by a psychologist to whom Bebensee had referred the child for a second opinion. Id. at 286-87.
At a hearing related to father’s visitation rights, Bebensee testified that there was no doubt that the father had sexually abused his daughter. However, the court appointed psychologist filed an affidavit with the court stating that he had serious concerns about Bebensee’s actions, in part because “psychological testing of the child disclosed that she so confused fantasy with reality that she could report fantasy as fact and use appropriate body language in doing so.” The affidavit also noted that the therapist did no psychological testing on the child; she did not investigate the reports the child made to other parties as to whether they were consistent or inconsistent with the statements made to her; she refused to speak to the father before diagnosing him as the child abuser; she disregarded reports of other professionals; and, she advised the mother to limit visitation rights. Id. at 287-88.
Based on these facts, the court concluded that Bebensee owed a duty of care to the father:
We reach this conclusion after considering both the great social utility of having therapists make reports of suspected child abuse and the significant risk of substantial injury that may occur to one who is falsely accused of being a child abuser. Certainly, the harm that may result from negligent false accusations is readily foreseeable, while the burden of care placed upon the therapists is no greater than the duty that substantially all professionals are required to meet. Thus, a mental health care provider owes a duty to any person, who is the subject of any public report or other adverse recommendation by that provider, to use due care in formulating any opinion upon which such a report or recommendation is based.
Id. at 288-89.
These cases illustrate that, before reaching the conclusion that a therapist owes a duty to the alleged abuser, a court must balance various policy considerations. A court must consider the great social benefit of uncovering sexual abuse and, at the same time, recognize that determinations of sexual abuse necessarily affect both the victim and the alleged abuser, and that such a determination should be carefully made and should not be reached in a negligent manner. Specifically, the courts in these cases have examined: the injury that may occur as a result of being labeled a child abuser; the concern that many therapists become too involved in legal proceedings against the alleged abuser; the devastating affect a misdiagnosis can have on the family relationships; and, the detrimental effect of a misdiagnosis on the child. After finding that a therapist owed a duty to the parents (or grandparents), the court, in each instance, concluded that the therapist failed to exercise reasonable judgment in reaching the conclusion that sexual abuse took place and, as a result, the alleged abusers suffered foreseeable harm. Thus, *1156these courts utilized a traditional negligence analysis in reaching the merits of each claim.
We find the analysis in these cases provide a workable approach in determining whether a therapist owes a duty of care to an alleged child abuser in Pennsylvania. Moreover, it is wholly consistent with the approach taken by courts in this jurisdiction in determining whether a physician owes a duty to individuals outside the physician-patient relationship in the context of communicable diseases. DiMarco, swpra; Troxel, supra In other words, where the policies limiting a professional’s liability “pale in comparison to the harm at issue,” the lack of a psychiatrist-patient relationship should not bar recovery. DiMarco, supra.
Accordingly, based on the above case law and after considering the competing policies involved, we conclude that Dr. Cohen owed a duty of care not only to Nicole but also to the Althauses, because (1) Dr. Cohen specifically treated Nicole for parental sexual abuse; (2) the Althauses were directly affected by Dr. Cohen’s failure to properly diagnose and treat Nicole; (3) Dr. Cohen was both aware that criminal proceedings were initiated against the Althauses as a result of Nicole’s allegations and also actively participated in them; and (4) it was reasonably foreseeable that the Althauses would be harmed by Dr. Cohen’s negligent diagnosis.
The facts of this case support such a conclusion. Dr. Cohen repeatedly stated that she was not required to make any credibility determinations regarding Nicole’s allegations. In doing so, she made no investigation of the reports made by Nicole to other individuals to determine whether Nicole’s statements were consistent or inconsistent with the statements made to her; she completely disregarded the reports of other professionals; she never spoke to the Althauses; and she never directly challenged Nicole regarding her outlandish allegations of abuse despite the fact Dr. Cohen knew that they could not be true. Yet, at the same time, she was constantly aware of the criminal proceedings initiated against the Althauses and, in fact, was actively involved in them. On numerous occasions, Dr. Cohen testified at court proceedings on Nicole’s behalf and at other times, accompanied Nicole to preliminary hearings where she heard Nicole testify against her parents to facts which she knew could not be true. She further acknowledged that she occasionally doubted Nicole’s allegations and conceded at Nicole’s competency hearing that Nicole at times could not distinguish fact from fantasy.
Thus, we cannot conclude that Dr. Cohen’s actions were solely part of her therapeutic treatment of Nicole; rather, Dr. Cohen became deeply enmeshed in legal proceedings against the Althauses and, in doing so, placed herself in a role that extended well-beyond the therapeutic treatment context. It is clear that Dr. Cohen was not adequately prepared for such a role as she fully admitted that she never performed a diagnostic evaluation on Nicole. She never made any determination regarding Nicole’s allegations and relied on the conclusion of others that Nicole had been sexually abused. However, because she chose to take on this active role, the Althauses, as alleged child abusers, had a reasonable expectation that Dr. Cohen’s diagnosis of Nicole, affecting them as it did, would be carefully made and would not be reached in a negligent manner. Further, Dr. Cohen’s negligent treatment of Nicole combined with her subsequent course of action against the Althauses resulted in foreseeable harm to the Althauses, as specifically identified parties.
In reaching this conclusion, we reject the approach taken by the Texas Supreme Court in Bird v. W.C.W., 868 S.W.2d 767 (Tex.1994). In Bird, the mother, claiming her son had reported that “daddy” had sexually abused him, sought counselling for her son. W.C.W. v. Bird, 840 S.W.2d 50, 51 (Tex.Ct.App.1992), rev’d, 868 S.W.2d 767 (Tex.1994). The therapist briefly examined the boy and interviewed the mother and her common law husband. The child told the therapist that “daddy” had abused him, but the therapist later admitted that she did not know if “daddy” was the child’s biological father or his mother’s common law husband. Despite her doubts, the therapist signed an affidavit stating that the child had been abused by his biological father. After further investigation, a court-appointed therapist later concluded *1157after lengthier interviews that the boy had not been abused by his biological father. Id. at 51-52.
In rejecting the claim that the therapist owed a duty to persons outside of the therapeutic relationship, the Texas Supreme Court stated that although the risk of injury from misdiagnosis is certain to occur, there is great social utility in encouraging mental health professionals to diagnose sexual abuse. Bird v. W.C.W., supra, at 769. We do not adopt the analysis in Bird because it focused on only one consideration—the utility of diagnosing sexual abuse. While we recognize that great social utility arises from allowing therapists to diagnose sexual abuse, no social utility can be derived from shielding therapists who make cavalier diagnoses that have profound detrimental effects on the lives of the accused and their family as recognized by the courts in Caryl S., supra, James W., supra and Montoya, supra. Further, as the concurring opinion in Bird warns, the decision “should not be read as conferring a grant of absolute immunity upon mental health professionals.” Id. at 772 (Gammage, J., concurring, joined by Doggett, J.) Instead, the concurring opinion noted that:
Every privilege carries with it a responsibility. If we are to grant mental health professionals the privilege of making such accusations, even if they are not called upon to make them, we also should hold them to an appropriate standard of professional responsibility.... Though we should give mental health workers in this field some latitude and protection in their efforts to eradicate child abuse, commensurate standards of professional discretion should apply, and failure to adhere to such standards could foreseeably result in their judicial recognition and enforcement.
Id, at 772-73. Thus, as the concurring opinion suggests, therapists should not be afforded blanket immunity in every instance.
Finally, we find that imposing such a duty on therapists requires no more than what a therapist is already bound to provide—a competent and carefully considered professional judgment. When that therapist then embarks upon a course of action directed against the accused based on that professional judgment, a therapist owes a duty of care to the accused. Here, Dr. Cohen failed to properly diagnose Nicole and, consequently, provided her with substandard treatment. Further, we conclude that Dr. Cohen’s subsequent action directed at the Althauses caused harm to them that was reasonably foreseeable. Accordingly, we find that, under the particular circumstances of this ease, Dr. Cohen owed a duty of care to the Althauses.
Dr. Cohen and WPIC next argue that they should be awarded a new trial on both the Althauses’ and their daughter Nicole’s negligence claims because the trial court erred in refusing to allow the jury to consider whether their negligence contributed to their own injuries. The standard for determining whether a jury instruction on contributory negligence is warranted is well-established.
If there is some evidence of contributory negligence, the issue should be submitted to the jury. McCollough [McCullough] v. Monroeville Home Ass’n, Etc., 270 Pa.Super. 428, 411 A.2d 794, 795 (1979). However, the burden of establishing contributory negligence rests on the defendant. Id. at 431, 411 A.2d at 795. Additionally, for a plaintiff’s negligent conduct to effect his recovery, his conduct must be a proximate cause of his injury. Koelle v. Philadelphia Electric Co., 443 Pa. 35, 42, 277 A.2d 350, 354 (1971). In order for negligent conduct to be a proximate cause of an injury it must be a substantial factual cause of the injury for which damages are sought. Dornon v. Johnston, 421 Pa. 58, 60, 218 A.2d 808, 809 (1966).
Pascal v. Carter, 436 Pa.Super. 40, 43, 647 A.2d 231, 233 (1994).
With respect to the Althauses’ alleged negligence, Dr. Cohen and WPIC argue that certain decisions made by the Althauses throughout this ordeal may have “lengthened the period of time that passed before Nicole announced her refusal to testify and ultimately recanted her abuse claims.” Brief for Appellant at 29. Specifically, Dr. Cohen and WPIC point to the fact that (1) the Althauses had the opportunity to meet with Nicole and CYS to discuss the charges on the day that Nicole initially made them and instead chose *1158to meet with their attorney; (2) Mrs. Al-thaus, who was given several options by CYS relating to Nicole’s placement, should have opted to remove Mr. Althaus from the family home; and (3) the Althauses waited six days before attempting to meet with Nicole and over eight months before requesting a psychiatric evaluation of Nicole.
Dr. Cohen and WPIC cite several cases to support their contention that the Althauses’ conduct established some evidence of negligence. See Levine v. Rosen, 394 Pa.Super. 178, 575 A.2d 579 (1990), aff'd, 532 Pa. 512, 616 A.2d 623 (1992) (jury instruction on contributory negligence in a medical malpractice action proper where evidence suggested that the patient had failed to report her symptoms to the doctor and had scheduled mam-mographies without the doctor’s knowledge); Morganstein v. House, 377 Pa.Super. 512, 520, 547 A.2d 1180, 1184 (1988) (evidence in medical malpractice case of patient’s failure to follow his physician’s instructions was sufficient to warrant jury instruction on contributory negligence); Berry v. J.R. Friday, 324 Pa.Super. 499, 472 A.2d 191 (1984) (jury instruction on contributory negligence in medical malpractice action appropriate where evidence established that patient, as an overweight smoker and drinker, could have caused his heart attack). These cases address situations where there was evidence of a patient’s negligence in pursuing his or her own medical treatment. In each instance, a jury instruction was appropriate because the evidence suggested that the patient’s conduct could have been a “substantial factual cause” of his or her medical injury-
However, these cases provide no support for the contention that a jury instruction is warranted here because the Althauses had no physician-patient relationship with Dr. Cohen and had no control over her treatment of their daughter Nicole. Rather, the testimony at trial established that Nicole’s undiagnosed condition progressively worsened under Dr. Cohen’s treatment and that Nicole’s allegations against her parents became increasingly more outlandish as a consequence. We fail to see how the Althauses’ conduct could even remotely establish that, had the Althauses chosen a different course of action, Dr. Cohen’s negligent treatment of their daughter and subsequent action directed against them would have been prevented or would have lessened their injuries. Thus, because we find no evidence of causation between the Althauses’ alleged contributory negligence and their injuries, the trial court did not err in refusing to instruct the juiy on contributory negligence with respect to the parents’ claims. See Pascal, supra (court erred in instructing the jury on contributory negligence where physician failed to show that minor and his father were contributorily negligent in failing to seek treatment earlier because there was no evidence presented that a proper diagnosis could have been made at an earlier date).
With respect to Nicole’s alleged contributory negligence, Dr. Cohen and WPIC point to the fact that “but for” Nicole’s allegations against her parents, there would be no lawsuit. However, Dr. Cohen and WPIC would have us ignore the fact that Nicole had a borderline personality disorder that Dr. Cohen negligently failed to diagnose and, consequently, provided Nicole with substandard treatment that further contributed to Nicole’s inability to distinguish fact from fantásy. As the trial court noted, “[i]t is precisely because Nicole was psychologically unstable that her representations to her treating therapist cannot be seen as contributory negligence.” Opinion, McLean, J., May 22, 1996, at 10. Because Dr. Cohen and WPIC cite no case law from this Commonwealth that would support a jury instruction on contributory negligence in such an instance, we find no error in the trial court’s refusal to submit such an instruction to the jury.
We now address the Althauses’ claims in their cross-appeal. Our review of the Althauses’ brief with respect to their first and second issues reveals that these claims are not supported by any legal authority; rather, we find a reiteration of the notes of testimony from trial and mere factual allegations. Pa.R.A.P. 2119. When a party has failed to cite any pertinent authority in support of a contention, the claim is waived. Fred E. Young, Inc. v. Brush Mountain, 697 *1159A.2d 984, 990 (Pa.Super.1997), appeal denied, — Pa. -, — A.2d - (1998). Accordingly, we find the Althauses’ first and second issues to be waived.
In their third issue on appeal, the Althauses argue that the court erred in failing to instruct the jury on punitive damages.
[T]he purpose of punitive damages is to punish outrageous and egregious conduct done in a reckless disregard of another’s rights; it serves a deterrence as well as a punishment function. Schecter v. Watkins, 395 Pa.Super. 363, 383-84, 577 A.2d 585, 595 (1990). Therefore, under the law of this Commonwealth, a court may award punitive damages only if an actor’s conduct was malicious, wanton, willful, oppressive, or exhibited a reckless indifference to the rights of others. SHV Coal, Inc. v. Continental Grain Co., 526 Pa. 489, 494, 587 A.2d 702, 704 (1991); Rizzo v. Haines, 520 Pa. 484, 555 A.2d 58 (1989).
Johnson v. Hyundai Motor America, 698 A.2d 631, 639 (Pa.Super.1997), appeal denied, — Pa. -, 712 A.2d 286 (1998). Here, we agree with the trial court that while Dr. Cohen’s actions amounted to professional negligence, there was not sufficient evidence of “outrageous conduct” to justify instructing the jury on punitive damages. Accordingly, the court properly denied the Althauses’ request.
In their final issue for review, the Althauses maintain that delay damages should be awarded to their daughter Nicole pursuant to Pa.R.C.P. 238. However, Rule 238 is only applicable in civil actions where a party is “seeking monetary relief for bodily injury, death or property damage.” See Hodges v. Rodriguez, 435 Pa.Super. 360, 377-79, 645 A.2d 1340, 1349-50 (1994) (collecting cases of non-applicability); compare Temporaries, Inc. v. Krane, 325 Pa.Super. 103, 115, 472 A.2d 668, 674 (1984) (tortious interference with contact; Rule 238 applies only to certain actions and does not encompass every action). We decline to extend Rule 238 to actions where a party is seeking relief for mental illness and therefore find this claim to be without merit.
Based on the foregoing, we AFFIRM the judgment in all respects.
McEWEN, President Judge, files a Concurring and Dissenting Statement, in which he joins the majority’s decision with respect to the duty of care owed by Dr. Cohen to the Althauses, but dissents with respect to the majority decision’s disposition of the Althaus-es’ cross-appeal.
TAMILIA, J., files a Concurring and Dissenting Opinion, in which he dissents from the majority’s disposition of the duty of care owed by Dr. Cohen to the Althauses, but joins the majority’s decision with respect to the Althauses’ cross-appeal. EAKIN, J., joins.
SCHILLER, J., files a Dissenting Opinion, in which he dissents from the majority’s disposition of the duty of care owed by Dr. Cohen to the Althauses. BECK and EA-KIN, JJ., join.