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Does A Therapist Have To Report Me As Suicidal If I Tell Her I Self Injure?

Question:

I’m a 27-year-old woman who has struggled with self-injury (cutting, burning) since early childhood, when I experienced physical, mental and sexual abuse. I desperately want to seek help for myself, but I have some concerns. If I speak to a therapist about my self-harming, will s/he be obligated to report my self-injury in the same way as s/he would be obligated to report issues related to suicide? I have attempted suicide in the past (5-6 years ago) and while I’m depressed and struggle with anxiety, I have no plans to attempt suicide. I’m just concerned that all of these factors together will result in any therapist I work with wanting to hospitalize me. If that’s the help I need then I’m guardedly open to it, but obviously I’d rather not go that route if it’s not necessary. What are a therapist’s obligation regarding reporting a clients’ problems with self-injury? I know you can’t answer every question.. but please, I’m pretty much begging you to answer this one. I’m afraid and I don’t know what to do. Thank you.

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Answer:

There isn’t a cut and dry answer to this question. Self injury falls in a sort of gray area in between what is reportable and what isn’t. I should define "reportable". to be very clear, what I have to say here applies to the United States of America only; other countries will have different rules in place.

In most USA jurisdictions, psychotherapists (at least the licensed ones) are mandated by state law to report certain behaviors to responsible authorities (e.g., the police, physicians, etc.). The exact definition of what is reportable varies from state to state, but generally has to do with the state’s desire to prevent people from harming themselves or others. Abuse of other people is almost always a reportable issue no matter what age the victim may be. Homicidal intent is always a reportable issue, and so is suicidal intent. The idea is to prevent people from harming themselves or others. With regard to stopping abuse, the intent is to prevent both physical and emotional harm to others. however, with regard to suicide, the assumption seems to be that no sane person would ever want to kill themselves, and the standard is that there is never a time when it is legitimate for someone to want to harm themselves. No exceptions are made for terminally ill people who would like to avoid pain and suffering, etc., unless this is specifically provided for by other state law (e.g., the State of Oregon may have different rules but I’m not sure about that).

Licensed psychotherapists generally also have a legal and ethical duty to protect their patient’s privacy. Psychologists can invoke a legal privilege to not reveal what their patients tell them in confidence, much like lawyers. However, the state’s interest in preserving life and preventing abuse trumps the right to confidentiality. Psychologists who do not report when they are supposed to report can face legal sanctions. Most professional groups have designed their ethical policies to match state law, so there are few cases where a professions’ ethics would compel them to take a stand that the state would consider illegal.

All of these issues should be explained to patients by therapists during their first therapy meeting during the part of that meeting where informed consent takes place. This sort of stuff should be documented in writing, and many therapists like to get patients to sign off on a paper saying that they understand the rules. Of course, these issues of what is safe to talk about and what isn’t also need to be discussed for as long as proves necessary to make them clear in the mind of the patient.

Self injury is a very different animal than Suicide, but this distinction is not well understood by all therapists. Especially new and relatively inexperienced therapists, and therapists who are feeling the need to be more rather than less cautious may mistake self-injury for suicide and pull the trigger on reporting.

If you think about the situation from the perspective of a therapist, the temptation to report when someone tells you they are engaged in a risky and potentially lethal set of behaviors such as self-injury is very high. The therapist has a duty on multiple levels to create an atmosphere of safety for the patient. Sometimes patients will act in ways that are impulsive and dangerous, and it is the therapist’s duty to try to limit those behaviors as much as possible, not unlike a parent’s duty is also to limit a child’s impulsive behavior. I don’t use this comparison lightly; therapy in some cases is equivalent to emotional re-parenting, and reigning in is necessary to promote the patient’s ultimate health, and not their momentary comfort. The therapist has no way to know what constitutes safe self-injury and what doesn’t. If the patient is new to the therapist and there is no track record, the therapist has no way of knowing if the patient is likely to be under or over representing the degree to which they are able to keep themselves safe. Many people who self injure will report suicidal ideation and other signs that are consistent with an elevated suicide risk. In sum, the therapist has to feel comfortable that the patient is not actually in acute risk of harming herself, and there is often no basis for making that judgment other than one’s gut and the word of the patient which isn’t worth much when there is no pre-existing, long standing relationship to base a judgment on. The therapist simply must make a decision, and then document her reasons for why she has made that decision, so that in the event that she is wrong, and an actual suicide occurs, she is able to justify her decision to the authorities who will investigate that death. It is very tempting to just be cautious and send people to the hospital at the first sign of danger. It is also tempting to restrict one’s practice to not work with people who self-injury, as this puts you at unnecessary risk of a serious career-threatening lawsuit. What I’m saying is that it takes serious balls and serious compassion to work with patients who self-injure because of these legal risks, and people don’t generally appreciate that, and should.

Every therapist faced with self-injury would report if there weren’t serious therapeutic downsides to reporting. Patients who are reported on will inevitably feel betrayed, even if they logically can understand why the therapist chose to report. This will generally make further therapy difficult or impossible, and sometimes patients will generalize and feel that they cannot trust any therapist (not just the one who reported). Sometimes temporary hospitalization is really necessary for the simple containment and medication reset it can provide, but the cost of that is very high indeed if patients lose trust in the safety of the therapy environment. The need to preserve a fragile trust, which is in the long term healing interest of the patient, is the reason why more reporting does not occur.

There are many therapists out there who are comfortable with the ambiguity and the risk of self-injuring patients, and also a bunch who aren’t. The only way to know about what your therapist’s philosophy is about self-injury is to ask, ideally during the first session or two you have with her, before you become an official patient. You don’t need to admit anything to ask "what is your reporting policy on self-injury?", and if you don’t like what you hear, you can walk out the door before you have agreed to enter a therapy relationship. This is a fluid boundary (as to when you become a patient), admittedly, but it will never be as loose or gray as it is during the first getting to know you session.

I recommend that you specifically seek out and work with a therapist who can offer you Dialectical Behavior Therapy (DBT) for several reasons. DBT is specifically designed for people who self-injure, so by definition, a therapist who offers DBT is comfortable with working with self-injuring patients and understands the distinction between self-injury and suicide. DBT is known to be helpful for self-injuring patients, for another reason (and you want to do something that has a good chance of helping). DBT has protocols for working with suicidal and self-injuring patients, so ask the therapist to go over them with you. There will be rules. For instance, you will be encouraged to call before you act out something suicidal so that you can work out a way to avoid doing it. If you self-injure with suicidal intent and then show up later to mop it up, the therapist will help you, but also likely provide a consequence, such as your not being able to go back to therapy for a while. You need to know what the rules are with regard to whatever form of therapy you go to, so I strongly encourage you to ask.

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Comments
  • Kitty

    Thank - you for asking that question. I have been hospitalized several times due to cutting. I was not seeking to end my life just relief from the stress and pain at the moment.

    This answer helped me to understand why the therapist did what he did by sending me to the hospital.

  • Anonymous-1

    Hi, Thank you to the person who asked that question and the doctor who provided the answer. I would just like to also add that there are some cases where hospitalisation is clearly appropriate and the assessor is reluctant to admit the person due to the fact that hospitalization will be seen as more harmful than helpful for a person or that they are not really suicidal but "attention-seeking". In my case, I was brought in to a hospital by police after serious concern for my safety (found near a cliff). I was deemed to have BPD and therefore not seriously suicidal (this is despite the fact that I admitted I was) and then discharged immediately with no follow up. Two weeks later I made an attempt and was on life support. After this, I became reluctant to admit I was suicidal for fear of being rejected as an attention-seeker. When I woke up from my coma I denied it was a suicide attempt for fear of being labelled an attention-seeker which is humiliating and hurtful when you openly ask for help and want to feel safe. There is a catch 22 situation it seems. If you ask for help you are an attention seeker and for fear of being labelled so pejoratively you keep your self -injury behaviours to yourself and do not receive help anyway.

  • Anonymous-2

    I am currently a self harmer and actively susidal. Scared to deth at this point. My husband stoped me this morning and Ive writen a note he hasnt found yet. But your comments about talking to your therapest and his or hur oblagation to report may just stop me from comiting suside. You see I trust him and well maby if we talk he would put me somplace safe. Im realy scared right now hearing voices ectra....So I want to say thanks for the courage you helped me with and I will call my therapest now.....L

  • anonymous

    I was hospitalized for self-injury and thoughts (not plans) of suicide and while the increased medication and enforced hospital stay did not help, I am now very afraid to report my true feelings to anyone and have actively avoided therapy, leaving me with no one to trust.

    In the US, ethics usually doesn't have anything to do with it: as my callous former therapist explained to me, he was having me hospitalized because federal liability laws encouraged him to do so. These laws permit relatives of suicides to sue mental health care workers for neglect, and that's why you see rampant overhospitalization of patients in America.

  • Allan N Schwartz

    Hello Anonymous,

    As a retired therapist with 30 years of experience both in Out Patient Clinics, Hospitals and Private Practice I am surprised to learn that you were hospitalized for "self injury." Believe it or not, the hospitals are very reluctant to hospitalize and for several reasons, the primary one being that it it extremely expensive. I have seen them turn away patients with suicidal ideation or thoughts but who, they decided, had no intent. That is why I rather suspect that they must have been convinced that you were suicidal when they admitted you to the hospital. This is the reason why I want to encourage you to be honest with your therapist. Therapy cannot possibly work if you hold back the truth.

    Dr. Schwartz

  • Anonymous-3

    I couldn't agree with you more, and it's kind of nice to hear it from someone else. I've been cutting for years and intermittently, it HAS been more than just regular cutting where I just wanted to relieve mental pain. Then my sister tells me I'm just trying to get attention (although I was mortified when anyone saw the scars), and so I start cutting myself more serverely when I get really depressed and think about suicide so that no one says I'm just trying to get attention.

    There is an in-between, indecisive point that is really a dangerous state when all people chalk it up to is attention seeking. I was diagnosed w BPD as well, where they claim it's manipulative, despite the fact I never wanted anyone to find out I'd done it. Now I finally have a competent shrink who saw my motivation was different, and has now said it's bipolar II and believes I should report my old shrink for failing to even ask to see my wrist when I cut myself badly right before an appt and had blood all over my pants and it was seeping thru my shirt sleeve and he is a medical doctor--psychiatrist--and doesn't even ask to see it.

    I feel totally betrayed by him but also very lucky to be around still at this point. I was on the verge more than ever, as the depression has lasted over a yr--and he did nothing to protect or help me, as I think he just didn't want to take the time to do so. I so easily could have ended up doing it. He just said "so I'll see you next week?" and I didn't even answer him I was so depressed, and he went on with his schedule. I am considering filing a complaint, which is not something I ever saw myself doing, but he is dangerous to have out there. Honestly, what would a person have to do in order for someone like him to call a hospital for intervention???? Bleeding in his office and he does nothing. He simply did not care.

    To the guy I am responding to, I hope with all my heart you have gotten the right help and are doing better. I am trying. There are people out there, though hard to find in my case, that do care and are competent. I will throw some agnostic prayers your way and wish you all the best. It was nice to hear someone who understands. Take care,

    cj

  • Shotgun

    Thank you Dr. Dombeck for an thorough response. In my opinion the problem with the law is that people like myself would never admit to their therapist of having suicidal thoughts and plans. I'd rather end up dead than loose my freedom and possibly provide others the right to gain power of attorney over me and my assets. Let the therapists recommend the treatment not state legislatures.

  • Anonymous-4

    just found that my suicidal daughter was involved with unhealthy relationship with her therapist. She promised her that she would help her kill herself and did not inform us- she says patient / therapist confidentiality. What do i do now

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