Allan Schwartz, LCSW, Ph.D. was in private practice for more than thirty years. He is a Licensed Clinical Social Worker in the states
Can your therapist have you hospitalized?
On March 7, 2009 someone posted this comment entitled:
"Distrust of Therapists"
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"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 over hospitalization of patients in America."
The anonymous writer of the posting cited above raises an interesting moral, ethical and practical dilemma for patients and their psychotherapist. The dilemma has to do with the question of when it is or is not proper to have a patient sent to the hospital emergency room?
Whether the therapist is a Licensed Clinical Psychologist, Licensed Clinical Social Worker, Psychiatrist or Licensed Marriage and Family Therapist, there is an obligation on their part to intervene under certain types of circumstances. By "intervene" is meant that they must report that someone is in imminent danger. This obligation overrides laws of confidentiality. The reason for this is that, under these circumstances, it is clear that a patient is in danger of committing suicide or homicide. If there is clear evidence that a child is being abused, the therapist must report this, as well. Outside of suicide, homicide and child abuse, the laws of confidentiality hold sway.
How does "reporting" really work?
In the case of a patient whom the therapist is convinced is in danger of suicide, a call can be made to 911 to report the suicide and have them go to the patient’s home. In all of my years of practice there was one occasion where I asked 911 to come to my office and pick up the patient. I had to cancel my afternoon schedule to get this accomplished.
Other steps that can be taken are to call family, friends or neighbors and have them take the patient to the emergency room. One last possibility is to get the patient to go voluntarily go. The problem here is that, if someone is really suicidal and they are left to their own devices there is a good chance that they will attempt suicide.
Here is the KEY POINT in all of this:
Once sent to the emergency room of a hospital, there is absolutely no guarantee that a patient will be hospitalized. Instead, the hospital emergency room will do one of two things depending on where you live: 1. They will transfer the patient to a psychiatric hospital for evaluation or, 2. They have their own psychiatric emergency room and will do an evaluation right there.
In doing the evaluation, a group of psychiatrists, psychiatric nurses and clinical social workers, will decide whether or not the patient is truly suicidal and in need of hospitalization. Contrary to what the anonymous writer states above, it is not easy to be admitted to a psychiatric hospital. This is the reason why there is no such thing as "over hospitalization" in the United States. I have seen, on numerous occasions, where patients, brought to the hospital emergency room by 911 the emergency response team, were sent home.
In order to further elaborate on just how difficult it is to accomplish a psychiatric hospitalization, even if 911 is sent to the patient’s home, the emergency response team does an immediate evaluation and can decide that a trip to the ER is not necessary.
In my opinion, the writer of the note above, was admitted to the hospital because she was deemed to be dangerously suicidal.
I cannot and will not defend the actions of every therapist because I do not know who they are or how well trained and experienced they may be. However, in the case of those therapists I have known, from New York to Colorado and California, the only time they will call 911 is when the fear for the safety of the patient.
What about self injury?
There are too many people, both male and female, who injure themselves. The most common type of self injury is probably self cutting, often with a razor. The cuts usually leave scars that bear witness to the self cutting. As a result and in order to hide the scars, people wear long sleeves even during the summer and long pants. Cutting occurs on the arms, legs and other parts of the body.
The goal of self mutilation is rarely connected to suicide. Instead, the strategy is to feel the sense of calmness that is followed by an episode of cutting. It is speculated that this calmness stems from endorphins that create a almost a euphoric state.
Therefore, it is unlikely that a therapist will feel impelled to report self cutting. Of course, there can be exceptions as for example, if it is believed that suicide is the intention. Just to repeat, suicide is very rarely the goal of self cutting. It should go without having to say it that there is always the risk of cutting in the wrong place, hitting an artery and causing a deadly bleed out. In my individual experience I have not come across or read about such an occurrence.
In by opinion, a psychiatric hospital will not admit a patient for self cutting unless the evaluating team lead by the psychiatrist, determine that the individual is suicidal. This even happens in cases of Anorexia Nervosa in which a patient will not be admitted unless the body weight places them in danger of death.
In an age where hospital and medical costs continue to surge and in which health insurance companies are reluctant to reimburse, it is unlikely that anyone will be admitted for frivolous reasons.
It is true that trust is a key element to the successful completion of a psychotherapy. There are those times where a therapist may decide that a visit to the emergency room is important for a patient. In my experience, that happens with mutual cooperation between therapist and patient. Even in the case where I asked 911 to come to my office, the patient was cooperative, In fact, that individual was admitted and remained for quite a lengthy period (by today’s standards, one week) and was not angry upon returning to treatment.
Trust is important because only with trust, can a person be willing to talk about all that they are thinking about and feeling.
To answer the question within the title of this essay, a therapist can attempt to have you hospitalized if he has determined that you are in danger of attempting to kill yourself. However, in no way does that mean that, after being taken or going to the emergency room, will you be admitted. Only if you prove to the emergency room team and even the emergency response team, that you are suicidal, will you be admitted.
Your comments are encouraged.
Allan N. Schwartz, PhD
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