What happens when you tell your therapist you're not safe?
December 7, 2017 10:27 AM   Subscribe

I am safe and not currently suicidal, but I feel I could lose it in the near future. My only two attempts ever are both within the last year and I told my therapist this. This was not the main issue of discussion but we are creating a safety plan. What exactly happens when you tell your therapist this? I'm in the state of Minnesota. I'm trying to find specifics in order to prepare myself as I do plan on telling my therapist should things get so dire for me again. Thanks!
posted by signondiego to Human Relations (10 answers total) 1 user marked this as a favorite
They will assess whether they are professionally obligated to call an ambulance, basically. You can talk to your therapist about what that calculus would look like in your case.
posted by PMdixon at 10:57 AM on December 7, 2017

It's a little more complex than calling an ambulance of not. if you are anti-hospitalization for yourself, this should be included in your safety plan. You can come up with alternatives, that may be more comfortable or less frightening for you. I have worked on a plan that includes many options before hospital (we'll call that Plan X), and my therapist is a trauma specialist who does not consider themselves professionally obligated to do something that would infringe on my healing.

Here's a pretty simple WRAP plan template. It's worth looking into Peer Crisis Respites and warmlines as well. It's worth asking your therapist if they've done this in the past, and if they have experience working with suicidal patients. A very important part of your plan will being having a team: your doctor(s), your loved ones, who are safe people you can rely on in a situation of crisis.

I'm sorry this is something you have to think about and I wish you the best.
posted by colorblock sock at 12:06 PM on December 7, 2017 [8 favorites]

Therapists generally have a legal and ethical obligation to make reasonable efforts to prevent your from seriously harming yourself or others. If you tell a therapist that you feel unsafe, it is up to them to use their professional judgement as to the best response. There is a whole continuum of possible responses. This from the APA give you an idea of what therapists are supposed to thinking about.

Just thinking about killing yourself does not mean an automatic trip to the psych ward - that is only the proper response when the patient needs to be kept safe from themselves long enough for other treatment (especially medication) to begin working. this is where having a safety plan helps both you and your therapist figure out what to do in the moment.

I also recommend the WRAP plan colorblock linked to - it covers a lot of other related information that might need to be communicated to your team at the time.
posted by metahawk at 12:34 PM on December 7, 2017 [1 favorite]

The language I have heard used, in several different states, is "can you promise me you'll avoid harming yourself until our next appointment" or something similar. My daughter once answered no to this question based on philosophical grounds ("but dad, how can anyone ever be sure about something like that?") and almost found herself whisked off to the nearest mental health in-patient facility. If you are just thinking about it, and know that's all you're doing for the time-being, you can discuss it with your therapist. If you really feel there is some chance you could take your own life, your therapist is duty-bound to make sure you are in a safe place, which does not necessarily mean, but could mean, confinement.

You should make sure your therapist understands whether you are speculating about something that might happen in the future, or whether you are in crisis at the moment. It's certainly worth telling them what you told us.

I'm glad you're working with someone on this, and creating a plan. Constructive action is the enemy of depression.
posted by ubiquity at 12:58 PM on December 7, 2017

So the "this" you're worried about telling your therapist is that you feel a downswing coming? Say that. "I'm okay today, but I'm worried about the near future. Can we prioritize the safety plan today and get back to the other stuff afterwards/next time?"

I think an appropriate aspect of therapy is identifying patterns and warning signs and it's something you should be talking to them about. Many (most?) mood disorders are at least lightly cyclical, this is a reality that frequently has to be grappled with.
posted by Lyn Never at 1:39 PM on December 7, 2017

Oh, hey, this has happened to me a few times.

Definitely prioritize the safety plan. An ounce of prevention and all that, plus knowing what all the intervening non-nuclear steps are can be very reassuring. And you may identify tools you hadn't thought of, which is always good.

The last time I was hospitalized after disclosing that I wasn't safe (and this was in a student health center ten years ago in a different state, so obviously YMMV), the practitioner I was seeing took me to their head supervisor, who then sat me down and explained that they weren't allowed to let me leave, and they would be making some calls to coordinate having me admitted directly to a mental health unit (bypassing the ER, which is no fun under any circumstance but especially this one). I had to sit around in their office for a few hours while calls were made, and then I rode in a police escort call to the hospital, where I was admitted. Unfortunately, that meant that all I had was what was in my bookbag at the time, and I had to do some wrangling to get someone to bring me clothes and stuff later. I also didn't have to deal with having left a car somewhere because I was on my college campus.

I had a couple similar experiences earlier, with different outpatient practitioners and different hospitals. One time I had to go to the emergency room and it sucked a lot, so having someone who can admit you to a bed directly is far, far better.

There's absolutely nothing wrong with inpatient treatment if that's what you need to be safe. But if I had it to do over again in an ideal world, and I was going to an outpatient appointment that I suspected would end in not being allowed to go home, I would DEFINITELY try and have a family member or friend drive me and wait in the lobby during the appointment (so that you don't have to abandon a car, and so someone can be point person if work needs to be notified or pets need to be fed or someone needs to go pack you a bag of underwear and pajamas and a book to read), and if you can't go directly to admission and have to go via an emergency department, ensure that someone is there with you the entire time. You will want someone who isn't you handling logistical details and being your advocate.

It can totally suck and be scary or emotional to have to go through this but it is WAY BETTER THAN HURTING YOURSELF so let the folks on your team (care provider, friends, family, whatever) be on your team and help keep you safe. Good luck!
posted by bowtiesarecool at 2:03 PM on December 7, 2017 [1 favorite]

Response by poster: @Lyn Never, and others: This is exactly it, I feel a potential downswing coming, however I'm not worried about telling my therapist that. She did ask me if I was currently safe when I informed her of my prior suicide attempts.

My question really pertained to when I am literally in danger, as in there being extreme possibility of offing myself upon leaving the session. And not so much as just thinking or speculating about it.

Thanks for the support and for helping me realize that there are things to think about when it comes to building my safety plan. Suicide certainly isn't my goal here but I'd like to have all bases covered in the event it gets this far.
posted by signondiego at 2:03 PM on December 7, 2017

I am a psychologist, not your psychologist. I have practiced in MN. The answers above are right on. Your psychologist would have a discussion with you about whether you had a specific plan, over and above having suicidal thoughts. They would assess whether you had the means to carry out that plan (like access to a weapon or medications), and if so when you believed you would act on that plan. Depending on the answers to those questions, they may try to work through a safety plan, either one you've discussed before, or a new one depending on your particular circumstances. Things like, is there a way to get a gun out of the house before you return. Could someone stay with you? Are you willing to contract for your safety between now and your next appointment? Depending on the answers to those questions, they may feel that the risk is too great and work to make arrangements for some kind of crisis intervention. This could include anything from contacting a mental health crisis team to arranging some kind of transport to an emergency department, arranging direct inpatient admission, etc. They may also with your input put an alternative plan in place like keeping in contact with them between appointments at an agreed-upon time, contacting a warmline, participating in groups or other therapies, etc.

There are two competing vital principles in these situations. The first is to maintain your autonomy and privacy as much as possible as a client. The second is to safeguard your life and safety as much as possible. It can be a challenge to balance those two, but the goal is always to focus on what is best for the client.
posted by goggie at 2:20 PM on December 7, 2017 [3 favorites]

People are often at risk for self-harm as they start to feel better; it takes energy to self harm. You are smart to assess yourself. It can help to promise yourself that you will not hurt yourself before talking to the therapist. There's an article by Art Kleiner that has great meaning to me and has helped people I know who were considering suicide - How not to commit suicide. I hope htings get better, and it sounds like they will.
posted by theora55 at 4:00 PM on December 7, 2017 [1 favorite]

Your therapist should be fine with explaining exactly what would happen in all kinds of scenarios including being at their office at the time you need urgent assistance. A big part of the safety plan is making it as easy as possible to get help when you need it, and barriers to that vary depending on where you are, time of day etc, and anxiety about not knowing what to do is a big deal.

It sounds like maybe you're afraid they'll think you're making a (bad) plan by asking these things, but it's totally normal to be anxious about "what if I need help and don't know how to do it/it's scary/I do it wrong/I inconvenience someone" and a great way to defuse that anxiety is to rehearse - it's not rehearsing suicide, it's rehearsing recognizing a bad situation and getting help. It's a little bit like learning CPR or doing fire drills or reading the safety card on the airplane: so you'll already know what to do in the event of an emergency instead of having to come up with a good solution on the spot.
posted by Lyn Never at 4:52 PM on December 7, 2017 [1 favorite]

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