Under what circumstances would a mental health practicioner break confidentiality? Would the patient need to have actually made a suicidal gesture or attempt? Or would confessing thoughts of suicide be sufficient? What merits involuntary commitment? Would an adult’s next-of-kin be contacted against his will? Do hotlines trace phone calls? Is there anyway for someone who’s thinking about suicide to get treatment without confidentiality being breached or without running the risk of being committed?
Here’s a great link about Tarasoff - the legal case on point with your question - and (towards the bottom) how it’s been applied to suicide. Note that it just discusses everything in general terms, but here’s a relevant excerpt:
I am not a licensed provider, but I do work closely for them. As a non-licensed person working in the mental health field, I am required to report anyone who expressed suicidal ideations or homocidal ideations to my immediate supervisor (most of the time this person will be a licensed provider). We do not report to anyone not responsible for the patient’s care. We also attempt to get a safety contract with the “at risk” person. If that cannot be done, generally, we will try to get the patient to agree to stay with us or refer to an inpatient setting.
I am coming from a military perspective, and state and national laws may vary from this point on. We have the right to have a person ordered by his/her command to be admitted to an inpatient ward. Safety of the at risk person is the only concern, and usually once we can get a good safety contract, the person will be discharged from the inpatient ward, and be referred to outpatient mental health.
Sgt Schwartz
I am not a medical professional, but a member of my family has been at times suicidal and these comments are based on that. In our situation the highly ethical mental health practitioners did break patient confidentiality, and it was – literally – lifesaving. This was in situations where a suicide attempt had been made (or was in the process of being made). Next of kin were definitely notified.
Talking about suicidal thoughts with one’s therapist would not, in my observation, cause confidentiality to be breached, nor would it necessarily result in being committed involuntarily. In my opinion anyone with such thoughts should definitely find a therapist to talk things out with. If there is no imminent danger to one’s self (or others) requiring others being told, I don’t think that would happen. In fact, working with a mental health professional might well prevent it.
Involuntary commitment is (again just in my observation) done when it’s necessary to prevent suicide. For example, if a person was rescued from a suicide attempt and their actions and words indicated that they were likely to try again, they might well be committed involuntarily.
I don’t know about hotlines.
Psychologist here. There’s a difference between “I have thoughts of killing myself” (that’s a symptom) and “I’m going to kill myself the first chance I get and here’s how I’m going to do it with the large bottle of Atavan I have at home” (that’s an intention with a workable plan). Suicidal thoughts are a symptom of depression and something that patients need to be able to honestly reveal in the course of treatment. I have been practicing for about 15 years in California and have involuntarily hospitalized a patient only once*. We generally can come up with a mutually workable plan to ensure their safety with plenty of safeguards in place. And really, sometimes it’s a relief for people to go to the hospital if they are really really depressed. It takes the decision out of their hands. But it’s also a relief for a patient to be able to tell someone that they’ve been frightened by the suicidal thoughts that pop into their minds unbidden and that those thoughts are symptoms of their illness, not suggested courses of action. I very much want patients to feel safe having these conversations with me. I will say that I’m much more apt to strongly encourage a patient with serious suicidal ideation to consider a psychiatric consult. Antidepressants work so well so often with suicidal thoughts that I feel like it’s malpractice not to suggest it.
I’m avoiding answering your direct questions only because states have different laws governing confidentiality, etc. However,usually Tarasoff isn’t invoked for breaking confidentiality in cases of suicidality in California; a clinician MAY breach confidentiality in cases of danger to self under 5150. A clinician MUST breach confidentiality in cases of danger to others under Tarasoff.
Generally, involuntary committments are difficult to obtain (I’m leaving aside the issue of how difficult it is to find an empty bed at a facility RIGHT NOW or getting police to transport a patient to a hospital) and result only in a 72 hour observational hold. In that time, the patient’s case must be reviewed by a judge and the facility has to convince him/her that they patient is gravely disabled or in imminent danger of killing themselves or someone else. Again, I’m talking about California here.
If you’re asking for yourself, alphaboi, please don’t let this be the thing that keeps you from getting treatment. Discuss your concerns on the phone before you make your appointment, if possible. I also guarantee you’ll get an appointment quickly, which is as it should be.
*They called me in the middle of a suicide attempt that neither of us saw coming and I sent the paramedics to their home.
Also a psychologist. What** jellyblue** said. Again, laws vary state-by-state to some degree. Oregon, for example, has no “Tarasoff” law per se, and holds to a standard of immediacy. Some other states have looser criteria.
Under what circumstances would a mental health practicioner break confidentiality?
If a client (or other person I have a mandated reporting role about) was, in my clinical judgment, immediately at risk of harming himself or another person. If his judgment was impaired to the point where he could not make good decisions about harming himself or another person intentionally or unintentionally. If he had a history of a disorder that contributed to any of the above and was in the prodrome (early stages) of another episode. If I witnessed abuse of vulnerable persons as identified in my state law, or heard about it from a victim or some classes of witness. If I had an open release of information (e.g., a release to speak with a person’s relative, doctor, etc. without seeking further permission). In supervision if I were operating under another professional’s license. In order to bill the insurance company or third party payer identified by the client. In responses to a some kinds of subpoena if I were not able to convince a judge that I should not. To the client’s guardian if the client is not competent. If a third party ordered an evaluation or testing of the client and the client had agreed to this. To the holder of the client’s priviledge under some circumstances (e.g., the client has died). In any of these disclosures, I would be legally and ethically limited to providing only information necessary for protecting the safety of the client, other people, and possibly society (e.g., my client plans to blow up a bridge), and may do so without a release only until the standard of safety is met or immediacy is diminished, unless the holder of priviledge (e.g., the client or minor client’s guardian) authorized a further release.
I’ve done more involuntary admissions than** jellyblue,** but for many years I was a night psychiatric crisis interventionist. None of those people were happy to go, but all agreed that if they hadn’t, they would have tried to kill themselves.
Would the patient need to have actually made a suicidal gesture or attempt? Or would confessing thoughts of suicide be sufficient?
That’s going to vary somewhat by juresdiction, but usually the question is whether the client has a feasible plan, the means to enact it, and the intent to do so. Many people think about suicide. The question is whether someone seems to be at high risk for acting on those thoughts.
What merits involuntary commitment?
As above, this will depend on the laws in the client’s area. Even if hospitalization is required, we would rather have the client go voluntarily. At the hospital, a mental health evaluation will be performed. In my state, a person can’t be held if his judgment is not impaired, he denies the intent to commit suicide (actively or passively), and there is no contravening data to support initiating a hold. A hold is a period of observation after (or during) which the person may be released, or, if he meets the criteria above, and is not willing to remain hospitalized voluntarily, may be followed by a legal proceeding to determine whether he poses a risk to himself or others.
Would an adult’s next-of-kin be contacted against his will?
I believe the answer is generally no but there may be some circumstances in which they would, such as if the adult were incoherent and it was necessary to know more in order to provide emergency treatment. Generally, though, no.
Do hotlines trace phone calls?
Not the ones I’ve worked with.
**Is there anyway for someone who’s thinking about suicide to get treatment without confidentiality being breached or without running the risk of being committed?**As I said, many people think about suicide. A person could clarify with a potential therapist to what extent suicidality was an issue, whether it was a matter of thoughts about suicide or thoughts and a plan but with an agreement not to engage in the plan, or if the person is at some risk of killing himself. If a person is at some risk, the parameters of breaches of confidentiality and the options for voluntary treatment should be discussed with the potential therapist.
Therapists don’t want to breach confidentiality. As a profession, we see it as a last resort to protect people and decrease danger to vulnerable people (like kids).