Are there times when Psychologists are required to break confidentiality and report certain acts to the police or other authorities? For example, what if a client is doing drugs or wants to kill himself or someone else? Are there hard and fast rules on this, or is it open to the therapist’s interpretation?
You have just hit on a very large and complex issue that I will attempt to (in all likelihood, unsuccessfully) break down into a concise answer.
While confidentiality is a cornerstone of mental health practice there are times that all professionals need to break this trust. As a Psychologist I was trained to work from the following model (slightly truncated for sake of focus) for my adult clients:
If you have reason to believe that a client is an imminent danger to him/herself or someone else, then you must report this to the proper authorities.
Essentially this is a two-part model: harm to others and harm to self. And while it is a hard and fast rule, the language of the model is open to interpretation because of this concept of “imminence.” Ultimately, this often puts Psychologists in a position of working on a case-by-case basis and having to use their judgment to juggle many factors: obeying (and upholding) the law, maintaining the ethical standards of the profession, and watching out for the welfare of both the clients and society.
Consider first issues of harm to others, which is the easier dilemma to resolve. How do psychologists decide if a client’s future behavior toward others is “imminent?” For the most part they need to rely on clearly stated intent. I’ve had many clients express strong thoughts or even desires to hurt another person (some therapists call this “entertaining fantasies” of harm to others). A betrayed lover, an estranged business partner, even a softball buddy whose teammate dropped a game-ending pop-out. Many clients have had the urge to take a hockey stick to someone’s spinal cord. These feelings in and of themselves are not necessarily harmful. As a therapist, at times these fantasies can be frightening to hear, especially if it is unclear if and how the client will resolve them. What is important then is to help a client understand those thoughts and accompanying emotions and decide what he or she would like to do with them, ideally choosing not to take violent action. And, unless a client comes out and says “I am going to do ____ to so and so,” confidentiality remains intact because there is no proof of imminent danger to another.
I consider harm to self along two lines: direct and indirect. For example, as a graduate student, I had a client attend session under the influence of marijuana. The intoxication was fairly obvious due to his glassy eyes, slurred speech and the statement “Dude, I am so fucking baked out of my mind right now.” Is he an “imminent danger to himself?” Sitting in my graduate school office, which was small and now reeked of pot, probably not, unless he had smoked so much that he was about to die from toxic levels of THC. In other words, this was indirect harm, because his life was likely not in jeopardy. So although I was angry at him for not respecting our time enough to attend the session sober, I was not going to blow the whistle on him. This was in spite of the letter of the law which states that smoking marijuana is a crime in the United States. Was this silence because he was not likely to be in any imminent danger? Partly, but perhaps more importantly, he needed to know that he could actually show me who he is without fear of reprisal. We all have our demons. How helpful can a therapy relationship be if a client believes that revealing anything “bad” he or she has done will get them in trouble?
Most of my colleagues have reported to me that they do not report past, present or future use of illegal drugs to the police, regardless of substance, despite fact that they are viewed as a form of self-harm. Many practitioners treat drug abuse as an illness rather than a crime, and address it as such, again despite the letter of the law. This generally means consistently and cogently guiding the client toward avoiding habit-forming, illicit substances. I tend to adopt this philosophy as well, and if a client is showing any signs of addiction, the goal then is to get the client into a specific substance dependence program.
This intellectual “Fuck the Police” philosophy has its limits, however. This client (the stoned one in my office) had driven his car to session and planned on driving home. This put him at risk to hurt both himself and someone else (i.e., possible direct harm). Therefore I was forced to give him three options: lay down on the couch for the rest of the afternoon and sober up, walk home, or deal with the police if and when he got in his car because I would have called them as soon as he walked out the door with the intent to drive. This client actually resisted at first and got up to walk out, car keys in hand, but when he saw me pick up the phone he slumped into a chair and passed out, leaving me to see my other clients in a classmate’s office.
One renegade in the area of drug use and mental health is Dr. John, who will flat-out encourage his adult clients with chronic pain to smoke pot to cope with their physical difficulties. While many practitioners in mental health are certainly for the legalization of medicinal marijuana, most don’t have the guts to straight-up suggest its use to their clients. I’m included in that group, simply because I do not believe I have the requisite medical background to know all of the possible complications, side effects, and other nuances of marijuana and its impact on a person with physical ailments. What’s important here, however, is that Dr. John has decided to not balance the law with his clients’ well-being; rather, he has decided to take a direct stand and take matters into his own hands.
“To hell with that!” he yelled into the phone when I asked about his rogue philosophy on promoting illicit substance use. “There’s no way anyone with a brain could possibly think that getting someone fined or thrown in jail would be beneficial to their physical and psychological pain. If a client needs a couple of tokes to take the edge off, as long as they’re not developing a tolerance or not going to work or not being a functioning member of society, so be it. Oh, and your article about that woman calling you a racist was stupid.” He hung up before I had a chance to agree with him (about the pot, not the article) or thank him for contributing to this piece.
Now consider direct harm to self, which can again involve interpretation. Gina was attempting to cut her arms as a para-suicidal gesture. Her cut marks proved to be barely superficial, but suppose she cut deeply into a vein, either in session or immediately before. Because psychologists are not physicians it is often difficult to tell if a self-inflicted wound is potentially life-threatening. While situations like these are extremely rare in my practice, my general rule is to ask the client how she feels both physically and emotionally and to be equipped with gauze and band-aids if necessary.
During the year I worked intensively with Borderline Personality Disorder one of the clients made a deep slice on her wrist during a group therapy session. During the 10-minute break, she calmly and directly notified me of what she had done and showed me the wound. Although I was still training, I did by this point have some experience with this population, so the cutting in and of itself didn’t make me as skittish as I would have been one year earlier. However, it appeared as if she was losing more blood than a small cut would suggest. When I told her that I would get the first-aid kit for her to wrap the injury, she refused, saying “I’ve had enough. I’m going home to finish the job.” Was this a classic “cry for help?” She fled the building before I could find out why she made the cut or how she did it without anyone noticing. I was forced to call her husband and the police so that she could be taken to the hospital for both the physical wound and stated suicidal plan.
Now, many might be thinking, “Dr. Rob, who the hell are you to play God? If a person does not want to live, who are you to say she has to?” The above client thought the same. I and many other mental health professionals view suicidal thoughts and actions usually as a symptom of depression or at least extreme distress and not always an independent wish to die. I’ve said to many clients “I don’t think that you want to die. I think that you don’t want to be in pain anymore and that this is the only way you can see that pain going away.” Almost invariably they agree and, with appropriate intervention, those urges to hurt oneself can often, although not always, be eliminated. In other words, I’m not playing God, I’m trying to help a person see what the urges to die might truly be about. For the above client, my phone calls led to a two-week inpatient stay at the hospital, almost daily therapy with me upon her release, constant suicide monitoring by her husband, and lengthy conversations about why I violated her trust. Although angry at me for thwarting what was a firm decision to end her life, she understood my position. When I left that training position several months later she was still a very depressed woman but working very hard to change that.
There is another aspect to consider regarding suicide and therapy, independent of my personal beliefs. Attempted suicide is considered a crime in some parts of the United States and the Psychologist’s code requires that clients be sent to the local hospital if they are imminently suicidal (some call this “pink slipping”). I can’t speak for all mental health disciplines, but if you want to be a Psychologist, you are essentially signing up to sometimes force people into getting help, regardless of your view on the matter of “right to die.” If you want to be Dr. Kevorkian, that is all well and good, but give up your title of Psychologist first or don’t join the ranks altogether.
As mentioned, this is an extremely complex issue with multiple facets and plenty of interpretation involved in balancing the law, mental health ethics, and the well-being of clients and society. Mental health professionals devote much more than single posts to them, so I hope that this does at least some justice to such a grand topic. While Shrink Talk is generally a “lighter side of the field” site, issues such as self and other abuse command a certain level of seriousness. To both mental health clinicians and non-professionals, please feel free to add your own thoughts and examples in the comments thread. Don’t hesitate to inject your own wit, but keep it respectful or you’ll end up being abused yourself. By me.