Therapy and the Law

Dr. Rob,
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?

Ben


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.

(Visited 290 times, 1 visits today)

18 Responses to “Therapy and the Law”

  1. Newshoes says:

    I like your view of suicidal tendencies not as an independent choice but, in many cases, as an indicator of lack of happyness and power.
    In one small paragraph, you have answered the “who are you to play god?” question.
    I’m impressed.

  2. Amber says:

    Doesn’t every profession have a code of ethics somewhat similar to this?
    In the media it’s just as complicated. What can we print/report and what can’t we? Was it done publicly or by a public figure, was the person a minor? If that person was a minor and it’s done publicly does it still fall under the publicity ban law?
    What about when a person calls a radio station in the middle of the night to tell ask a personality to play a certain song because this is the end, how do you handle that? Who do you contact, or do you?
    And why is suicide such a touchy issue?
    Thank you for this blog Dr. Rob.

  3. Wayland says:

    Dr. John adds more of classiness. Haha. Just a little mistake at that part, “hung” and you meant to put “hung up”. Cool article. You’ve got a handle on your stuff : )

  4. Anonymous says:

    do no harm

  5. scootah says:

    unless he had smoked so much that he was about to die from toxic levels of THC
    Which would make him the second person to ever successfully do so by smoking it?
    God knows, many have tried and failed.

  6. Flora says:

    Amber: Suicide is such a touchy issue because, within a split second, you can kill yourself. It’s a simple answer, but hey… once you kill yourself, you can’t come back. Unless you believe in reincarnation, which still isn’t possible since the world never had a constant population.
    Newshoes: Why else would someone commit suicide? You don’t just walk around and one day say to yourself, “I feel like killing myself today.” It’s not that simple.

  7. Adam says:

    Dr. Rob,
    As well thought out as your posts are I have to educate you on one small fact. You cannot overdose on Marijuana. Trust me, you’ll just end up getting so stoned you’ll pass out. However, you can build up a dependancy and a resistence as you said, but you cannot ever OD on weed man 😛

  8. Luba says:

    Lovin Dr. John

  9. Amber says:

    Flora:
    I didn’t expect an answer, or at least that kind of answer. I should probably start rephrasing my questions. They come out sounding right to me but don’t always come across the same way to others.
    I meant that more as, in comparison to other realities. People are far more open about kinky freak sex, mental illnesses, sexual diseases, and other issues that they were never open to even five years ago. Why is it that talking about suicide is still such taboo? Wake up world, suicide is reality. My cousin’s grandmother committed suicide on the same day, but years later, that her daughter passed away from TSS. She just couldn’t handle living without her baby anymore. My husband’s grandmother committed suicide the year we got married, I never got a chance to meet her. The woman had LEFT A NOTE. Five years after her death the autopsy report came back. You know what it said? Inconclusive. Everyone knew she ODed. Everyone knew she did it on purpose. She left a note next to the empty prescription bottle. What pisses me off most about it, no one will talk about the issue. People tip toe around it. My mother in law is in some kind of black and white 1950’s perfect kind of world where people do no wrong and suicide just doesn’t happen. I know she’s grieved for her mother, but I don’t know that she’s actually accepted that she killed herself.
    The summer I turned 16 a kid I knew decided to play russian roulette by himself with his girlfriend sitting on his lap at a party. And of everyone I know that knows someone that committed suicide, my group of friends and I that summer were the only ones to talk about it. We got angry, we grieved.
    Heh, I almost forgot. A little over a year ago I met this man named Dave at broadcast school. He was a force of nature. He was an ‘entertainer’. He was just vibrating with life! He also had cancer. The man never drank, never smoked, was a deep believer in God, gave his life for his music and to bring positive energy to others. Would give you the shirt off his back if he could. I don’t remember the exact day but I remember the phone call. A classmate of mine called and told me that Dave had been very sick again, and we think he knew that he wasn’t going to make it this time around, the chemo and radiation weren’t helping. So Dave killed himself. He was sick of suffering. There was only one other person I could talk to about it, and it happened to be a friend that went to school with us and also battles severe depression for which he takes medication, and has fought urges of suicide for years.
    I don’t think about Dave as often now, but I remember being angry with him for months. I could understand he didn’t want to suffer, and he wanted to do it on his own terms. But I was so angry that he didn’t even try this time. He was barely older than my own mother. He was so young, so full of life, such a great example to society. I kind of hated him, I think, for taking himself away so early. Both of us were selfish. Him for killing himself, me for being angry.
    But why can’t I talk about this? Why do people get embarrassed and close up? Welcome to 2007. We talk about our bondage fetishes, our hatred of the guy that gave us some std, and other things we never used to, publicly. When is this going to be okay to talk about too?

  10. DanJ says:

    It’s nice to see this topic elucidated in greater depth. I’ve always known that the breech of confidentiality is typically related to imminent harm to self or others, but hadn’t realised how subjective and thorny this issue could be.
    My question is this: what’s the call on past offences? For example, let’s say a client told you they were feeling guilty because they’d stolen a car but had never been caught. They had no intention of doing so again, thus allaying any fears of imminent harm. However, they’d clearly admitted to a past felony. Would you be responsible/required/ethically motivated to turn them over to the cops? What about more personally harmful crimes? If they’d beaten someone up, or (god forbid) abused a child? If you felt they were unlikely to repeat this harm, but had committed it in the past, where does the burden lie?

  11. Tina says:

    I was a little disappointed that the there was an issue left out of this discussion all together. It is required that if a psychologist becomes aware of unreported sexual abuse, that he or she must report it to the authorities. I think there is a lot to be said about this rule, and i am curious about how many psychologists tend to handle it if and when it comes into question.
    Dr. Rob Note: The plan is to address this in a future post…

  12. Flora says:

    Amber, that was an interesting read. Sorry I don’t have much else to say…

  13. kate says:

    dr. rob at first i was annoyed by your grandiosity with the whole ‘playing god’ thing, but then i read past the first line and had to retype this sentence because i see that i’m actually saying the same thing you are, albeit more eloquently…!
    that woman in your BPD group didn’t want to die, she wanted to live and didn’t have any other means of verbalizing how much she needed your help in doing so at that given moment. i’m not trying to suggest that parasuicidal gestures shouldn’t be taken seriously–they are potentially life-threatening and should be treated as such–but interpreting what she did in terms of suicidal intent seems a little misconstrued.
    Dr. Rob Note: True, but Dialectical Behavior Therapy (DBT) is drastically different from psychoanalysis and its offshoots, and has a strict protocol on suicidal actions: they are not interpreted (at least not until they are under control). They are labeled as Therapy Interfering Behaviors and are not open to interpretation at that time, other than my question of “is this a classic cry for help?”. I could have clarified this in the post more comprehensively, but the interpretation of the behavior is moot at that point of the story. Those are very good points though. End Dr. Rob Note.
    She didn’t write a note. she didn’t develop a well thought-out strategy. she made her intentions known publicly to you and then busted out of there to see if you’d participate in her rescue fantasy. it’s classic BPD impulsivity and manipulation, and although i hate using the latter word to describe these behaviors (it implies conscious sadism on the part of the borderline, and i don’t think the manipulative aspect is particularly conscious), that was basically her only known litmus test for determining her self-worth in terms of the effort and concern of others. she would’ve been more pissed if you hadn’t called the cops.
    on some level i interpret certain parasuicidal gestures as (dare i say it)….healthy. these women have no objective vantage point from which organize their emotional pain. it’s as intangible as their sense of self, and yet it is persistent and unbearable. cutting makes the emotional pain a physical reality, and therefore helps organize that which cannot be understood due to the chaotic dysregulation of the borderline’s subjective emotional experience. i guess in non-pretentious terms what i’m saying is that cutting gives form to something formless, therefore making it real and accessible.
    if that woman’s gesture set a process in motion whereby her depression and internal chaos were taken seriously–her emotional turmoil was validated with two weeks of inpatient treatment & subsequent daily therapy with you & discussions about ‘violating’ her trust (reaction formation, imo)–then it served its purpose. she needed serious help and she didn’t know how to ask for it because she couldn’t verbalize what was wrong, so she did the only thing she could to make sense of her experience and make it known to others how bad things were for her.
    ps–please feel free to create an independent comment forum in which i can talk about this forever. we haven’t even touched on dissociation & cutting, which i find even more fascinating. you could call it ‘kate’s parasuicide forum,’ and although no one will ever read it, at least the people commenting here won’t have to scroll through essay after essay of my ramblings….just a thought.

  14. Kotenku says:

    “But why can’t I talk about this? Why do people get embarrassed and close up? Welcome to 2007. We talk about our bondage fetishes, our hatred of the guy that gave us some std, and other things we never used to, publicly. When is this going to be okay to talk about too?”
    Amber: Probably the day death can be treated with a shot of penicillin.
    I think the issue death is such a touchy subject is because while bondage fetishes and venereal disease are something that can be laughed at, or treated, death is, has always been, and will always be, the ultimate equalizer. It’s the grimmest and most inevitable thing about life. I think humans may be just genetically uncomfortable with any action that takes the seriousness and gravity away from the subject.
    Goodness, JFK jokes are still too soon.

  15. Anonymous says:

    Great post.
    May I also mention that this fear and silence of death is not a universal phenomenon. In a variety of other cultures death is not seen as the end, rather as the next stage, regardless of whether there is reincarnation or not. Biologically, it would make sense to fear death since it is one thing we are supposed to avoid. But I think that it’s also possible to become more comfortable with it if one tries to avoid the immediate fright impulses.

  16. Ember says:

    SO agreed on the “playing god” thing. As a survivor, I want to smack people who talk like that. Just because someone is overcome by the desire to die for long enough to kill herself doesn’t mean she’d be better off dead, or even that she genuinely believes that she would be. When the paramedics were forcing charcoal down my throat I wished they’d just leave me alone and let me make my own choices. But a few hours later, when I was lying in the ER with my mother crying over me, I was suddenly very glad that they didn’t.

  17. Rebecca says:

    Even though this is a very old post, I’m glad I could read it now.

    Not even a month ago, during what I thought was a routine therapy session, I made a comment along the lines of, “I want to go to sleep and never wake up again.” My therapist, a graduate student, erred on the side of caution and fetched his supervisor, who decided to send me to the hospital under Florida’s awesome Baker-Act law, even though I wasn’t suicidal.

    At first, I was very angry at my therapist and had a lot of time to ponder the whole “playing god” thing during my 72-hour hold (when I wasn’t telling staff I was going to chew my way through the fence if they didn’t let me out). I was also confused… I’d said a lot worse in therapy before and he’d never done anything close to this. In fact, part of the reason I’d asked for a male therapist initially was because female therapists had always been the more cautious ones who read too much into things.

    Eventually, I decided even though this was probably going to hurt the trust I’d developed for my therapist, I wasn’t going to let an otherwise good, 1.5-year relationship be destroyed by a single (albeit big) misunderstanding.

    I ultimately came to the conclusion that the whole thing was simply a sign that my therapist does care about my well-being.

    On breaking confidentiality and civil commitment, he says, “It’s not a perfect system.”

    Better to be safe than sorry, eh?

  18. Seviah says:

    My father-in law’s wife, my daughter’s favorite grandparent, loudly ideated over her suicidal intentions. She vacationed in the Netherlands. She tried to describe depression as a terminal illness. Eventually she waited until my father-in-law was at quartet so as to provide an airtight alibi. (Yes, they too are genuises; she went to Julliard dated new music composers, was one.) She locked the doors from the inside, used a chair and drugs. David and I were already separated, but it fell on me to tell Nissa. I was glad to see her cry unrestrainedly, as she later did when I had to inform her of her father’s death, and as she did again at the various memorial events I (wife again) orchestrated. David was unlucky, but there are no posthumous suicides.

Leave a Reply