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sk8rgrl23 March 5th, 2006 12:12 AM

When the therapist screws up
Okay, here's the skeleton of the situation. I got read the riot act by a client this week for something that I truthfully screwed up on. In a nutshell, I did a safety contract with a client, she followed through on her end, but it wasn't logged for some reason at the crisis center, I second guessed myself, and overreacted to the information I had, or didn't have in this case (apparently the client did call and check in and it was not noted) where there was a breach of confidentiality. Normally I"m really good with these situations, I have a pretty high threshold for crisis situations, and by now a fair amount of experience, and I"m honestly dumbfounded by how I dealt with the situaiton. I did meet with the client the next day, she aired her grievance with me in what I thought was an appropriate and respectful way. I didn't try to ignore her complaint and risk blowing what rapport we had left, and I didn't try to defend myself or get into a blame game, but I also didn't want to say anything that might increase liability for myself or the agency. The session ended apparently well, we discussed specific steps we would take next time there was a suicidal issue, including having every detail written down for both of us, and she seemed satisfied. I don't think this issue will go any further, and if it does I'll just have to work it out with my supervisors, one of whom I already consulted about the situation.

The client in question is on vacation next week, and I"m wondering if I should say anything more about this incident with her when she gets back, or if so, what. Mostly I just feel really bad about letting my emotions get in the way of good judgment and one thing I like to model for my clients is honesty and accountability. I also want to do everything I can to restore what has been a quality therapeutic relationship.

I don't want any "why did/didn't you" kind of feedback. What's done is done. I'm thinking everyone has some sort of moment like this in their professional lifetime, and maybe a good thread would be to talk about those incidents and how different people have handled it.

William Reid March 5th, 2006 04:42 PM

Re: When the therapist screws up
I don't understand how you "screwed up." Perhaps it has something do do with "logging it in"? I also don't understand how you may have breached confidentiality. Two general things come to mind, though:

First, as you may know (but it bears repeating), "contracts for safety" are not an effective way to prevent suicide. They should never be relied upon to reassure the therapist, take the place of other monitoring, or reduce risk by themselves. They may be helpful in a context of sharing one's concerns with a patient or enlisting the patient's participation in the therapeutic work, so long as there is already a good clinician-patient relationship and the patient doesn't get the idea that one is using the "contract" in place of really caring about the patient.

Second, when one is concerned about suicide, the concept of confidentiality must take a back seat to safety considerations. Confidentiality is important, but it is not cast in stone when the clinician is worried about either the patient's safety or that of someone else. When in doubt, consult with a senior colleague. (You do not need the patient's permission to do that.)

sk8rgrl23 March 5th, 2006 05:47 PM

Re: When the therapist screws up
Issue of timing. I didn't follow up till two days later, when I feel I should have been checking the next day, and could have easily called her phone no. In the end I did finally locate her number and left a message and she got back to me right away and said she was doing fine. There was also the communication thing on my part where I didn't check with the crisis worker to make sure she had left a message, and in fact she had not, so the client was upset about this. I guess I just feel like I dropped the ball in the communication department, and had I slowed down and thought it through, all my worry and overreacting might have been saved by a simple phone call.

Like I said, I think the situation is resolved, but from the information I have now, the client did follow through and called to check in when she was supposed to, and I just didn't get that piece of information. So truthfull I can understand her being a bit pissed when she apparently had held up her end of the bargain.

Da Friendly Puter Tech March 5th, 2006 06:01 PM

Re: When the therapist screws up
Hey Dr. Reid,

I am interested in why you say suicide contracts doesnt work.

I worked as a volunteer at a suicide and crisis hotline for more than three years. We used suicide contracts quite a bit, and I have seen positive results from it. Yes, they only work if the suicidal caller feels heard and cared about, but in those situations they can provide a good base to work the person.

I have a couple of specific callers in mind, when I say that I have seen suicide contracts work.

Of course, in the end, if a caller is really set on "doing it", then no amount of contracts, caring or outreach can really prevent it. When it has come to the point of calm determination for the suicidal person then it will take a lot to prevent the suicide. Even so, those folks often need someone to talk to in order to say "good bye" to their life, and it is possible that we get them on the phone while the suicide is in progress or eminent, in that case something can still be done.

However, before reaching that point of calm determination the suicidal person goes through several different stages, and during those stages quite a bit can be done to prevent the downward slide into seriously suicidal behavior. In my experience safety contracts really work on a majority of suicidal callers.

You also say that safety contracts should not be used to make a clinician feel better - I know on the hotline I sometimes used very short term contracts to even start the conversation with the client. An example is - "Can you put away the gun just for the duration of this conversation? I can hear this is so hard on you, and I just really want to hear what you have to say, and its hard when I know you have the gun in your hand while I talk with you."

That sort of statement often worked to get the immediate danger down to a level that could be managed. In one instance the caller was able to find her own chosen local helper rather than have me call in the police. I waited on the phone with her until that person was present.

I have seen several other situations where safety contracts provided the impetus or the sense of safety from the client to actually reach for help at the last critical moment. I am not sure those last minute situations could have been stopped if not for safety contracts, and the experience the caller had previously of being heard when the called us.

Certainly, suicide contracts are not a guarantee, that should not prevent anyone from using them though.

Da Friendly Puter Tech

William Reid March 5th, 2006 08:12 PM

Re: When the therapist screws up
Thanks for asking. This will be a little long. Sorry. For a more complete discussion (from my own viewpoint), folks are welcome to visit my website, go to the Columns/Full-Text page, and click on a last-year's article titled something like "No-Harm Contracts Redux."

No-harm "contracts" have enjoyed a lot of popularity. They were initially introduced (so far as I know) as parts of treatment, probably mostly informal communications in which the therapist gets the patient onto his or her wavelength in a sort of alliance against the mutual goal: symptom alleviation and, sometimes, survival. More recently, a lot of individual counselors and psychiatrists, emergency room docs, hospitals, and clinics have come to rely on written "contracts" not only to help patients but to decrease their own risk and liability for patients' suicides and other untoward behavior.

It's difficult to do studies which assess the usefulness of such "contracts" (notice how I insist on using quotation marks), but several have been done. In spite of anecdotal reports about "contracts" (which cannot reflect real effectiveness, though they may suggest patient or therapist satisfaction), every controlled study I've reviewed has found that the presence of such a "contract" does not reduce the risk of suicide. That's a very strong and important finding.

At least two studies (both from Minnesota, I think), also suggest that using "contracts" with emergency or crisis patients who have little relationship with the treater can create feelings of being "brushed off" (that is, the patient feels that the crisis counelor or ER doc used the "contract" to get him or her out of the clinic quickly rather than spend time with him).

Part of my point is that most truly suicidal patients don't think about their "contracts" when they are ready to kill themselves. Think about it: the morbid depression, etc., associated with true suicidality is such a strong influence on the patient's behavior that it overrides things like love of one's spouse and children, the well-being of one's family, strong religious prohibitions, personal wealth, etc. These people simply don't consider reasons to live; they see nothing except reasons to die. So-called "contracts" are no exception; they just aren't important when the chips are down.

Is it possible that a promise to a therapist could tip the balance toward survival, or get the person to call a therapist? Sure, it's possible. But it is foolhardy to bet the patient's life on that, for example by making the "contract" a major factor in deciding not to hospitalize, deciding not to seek consultation, deciding not to contact family or emergency authorities, or deciding to give a pass or discharge to a patient who otherwise may not be ready.

As most readers know, I do a lot of forensic work. The most common kinds of cases in my forensic caseload involve suicide. I see case after case, from all over the country, in which a clinician or team relied on a "contract for safety" when deciding to discharge the patient, refrain from hospitalizing the patient, or remove the patient from some kind of close observation status. It's often done as part of the effort to shorten the hospital stay, conserve staff resources, contain costs, or avoid seeing the patient more often. That's not only sad, it is often negligent.

So, my view, supported by the professional literature I believe, is that one may use lots of agreements with eligible patients (those who have the competence and ability to benefit from them) to assist in therapy, but when the chips are down, "contracts" are no substitute for careful (sometimes time-consuming) assessment, management, monitoring, and follow-up.

Da Friendly Puter Tech March 5th, 2006 10:31 PM

Re: When the therapist screws up
Hey Dr. Reid,

This is really interesting - are the studies you have read easily accessible for lay people? I would love to see one or both of them....

Whats interesting for me is that you and I speak from the exact opposite side.

You speak from the side where something has gone wrong.

On the crisis line I usually see the situation before it goes that wrong.

(btw, while i am no longer on the suicide hotline, I am currently on a rape crisis hotline so I am not out of touch with the potential callers)

Which means we have very, very different perspectives when we look at the issue.

Your point is well taken that relying on contracts exclusively to access safety is too limited. I can easily follow that, on the other side due to my experience with suicidal callers, I still think that contracts has a definite place in suicide intervention.

Few people that reach out for help when suicidal are at the last stages of suicidal ideation, where the decision to kill oneself invokes a sense of calm. Most suicidal callers are not there yet, and in those cases, taking the time to talk to them, connect with them, keep in touch with them, and contract for safety can have a big impact.

Da Friendly Puter Tech

sk8rgrl23 March 6th, 2006 12:06 AM

Re: When the therapist screws up
Journal articles should be easily available. If you can get on a university's database, you can pull up journal articles on almost any topic you can think of. I'd just go to the nearest university's library and ask a librarian what they have in the way of databases. Good luck wiht that!

sk8rgrl23 March 6th, 2006 12:18 AM

Re: When the therapist screws up
INteresting points, and yes, our emergency department makes heavy use of safety contracts. I understand your point that they don't really reduce suicide contracts, but I like them for a number of reasons. One, it is a good way to define the role of both therapist and clinet, and I have to think there's something helpful about writing up a concrete plan toward helping a client to not feel so overwhelmed. Another is that it gives us more good information to evaluate a client's abilty to follow through. The more specific, the more support sources, the more available the resources, the more likely I am to believe a client can go home. I think from a liability standpoint, a safety contract must at least demosntrate that there has been some discussion about the suicidal ideas and some attention paid to how at risk the client actually is.

As for clients feeling they've been brushed off, we have a recurrent problem of a few repeat clients that have come to know the right things to say to get themselves hospitalized. I get a littlle dumbfounded as to why anyone would want to work so hard to get INTO a hospital-I'd much prefer a week to myself in Puerto Back Yard, but that's beside the point. Nevertheless, for us to hospitalize people in this group can be detrimental in the long term. I'm sure some feel brushed off, but to give them what they want teaches them that going to the emergency room and lying about their situaiton works, and reinforces that going to the hospital is a good way to not deal iwth problems. Too often these are people that have not followed through with recommended treatments and use the hospital as a first, rather than as a last, resort.

Evaluating for hospitalization is to a large degree a gamble. WE try to explain this to emergency room doctors all the time, when they get upset with our decision to not hospitalize a client. It's not like blood levels, or temperature. It can't be measured in numbers-although we are about to get a new form that is a sort of a checklist that may very well put the whole thing to numbers.

William Reid March 6th, 2006 11:23 AM

Re: When the therapist screws up
Good points. Suicide hotlines, crisis counseling, etc., often deal with people who are not in an immediately lethal situation (that doesn't at all mean the crisis isn't real, or that the counter-suicide counseling isn't very important, nor does it mean that inadequately-trained professionals should man those phones or crisis centers). A certain number of callers, perhaps most, are calling for some reason that doesn't reflect a potentially lethal situation, but it is often hard to differentiate those from the ones who are more likely to make an attempt or -- very important -- whose conditions or behaviors are unstable. Instability and unpredictability are among the most important suicide risk factors.

The above also means -- and this is one of my big areas of interest these days -- that the interviewer should be trained, experienced, and prepared to do either (1) as comprehensive an assessment as is feasible under the circumstances or (2) a very competent screening which liberally passes "positive" patients along to someone who can do a more comprehensive assessment or at least work with more complex situations. Such things are certainly more difficult when dealing with a telephone hotline, where one can't see the patient, doesn't know the accuracy of the communications, often can't get to collateral information sources, and has little control over whether or not the patient follows recommendations (such as "go to the emergency room"). Perhaps most telephone hotlines shouldn't even be called "screening."

That brings up an interesting conundrum: Some clinics and hotlines use their less experienced folks for the screening role. "Screening" implies casting a very wide net, using basic questions that will catch most or all of the important cases. The questions are often pretty rote, with simple decision trees. Good screening should result in lots of "false positives," which are caught at the next levels of assessment.

Some "screening" is actually more like "triage." In triage, an experienced evaluator makes rapid decisions, usually under pressure (such as during a disaster), about who gets what kind of treatment, or no treatment. Triage requires a very well trained & experienced person (since important decisions are being made for which there may be no appeal). If your "screening" setting sounds more like a "triage" setting, then the people who man it should not be entry-level or marginally-trained professionals.

As to the literature on safety contracts: The best place to get a large list is at PubMed (the National Library of Medicine's online service, which provides references, abstracts, help with searches, etc.) That's where I looked when doing an article on the topic last year.

Da Friendly Puter Tech March 6th, 2006 02:39 PM

Re: When the therapist screws up
Hey Dr. Reid,

Interesting perspective you bring to the table, and again, I note that your experience focus's on when something actually has gone wrong.

Your points are of course great - it would be best to have well trained, fully educated, very experienced personnel to handle the details of suicide evaluation and prevention.

In all honesty though, I have to shake my head here. Show me any community in the US that takes good care of their financially poor mentally ill population? How much resources do we give to this population who needs a lot of resources?

Reality is - the suicide and crisis hotlines operate on a string budget. Often there is only one MFT associated with the line, and the rest are volunteers like me - without a degree, but with the desire to talk to mentally ill, suicidal people or people in crisis, even let those folks wake us up at at 3am, because they are having a bad night.

Most of us really wants to be there for folks in crisis, and we have some training, I think the training I got was pretty damn good. That still doesnt change the fact that we dont have a degree.

In my experience the less well trained of the suicide and crisis hotlines are mainly focused on a quick suicide assesment, and giving out resources. The best of the hotlines have volunteers who take the time to talk to, listen to and care about the callers. They are not all equal. In the cases were we - admittedly uneducated - volunteers take the time to talk to someone in crisis, often making these calls hour long, or longer, I think we make a big difference. I also think that we do a good job at keeping an eye out for actual suicide risk, vs suicidal ideation. In the cases where there is little immediate risk, but quite a bit of ideation we usually contract to call us back when / if it gets unbearable. I have gotten a lot of those calls that start out "I promised to call back if its unbearable, and it really is unbearable, I want to use x weapon now - I just cant handle any more". Would they have called without a contract? Maybe! One thing is for sure - with the contract they know that their call is welcome, and they have an actual plan to fall back on when they are completely overwhelmed and their cognitive processes might not be the greatest.

You also say that more should be done to take care of those callers that have been referred to the hospital for treatment. I couldnt agree more! I have been in a couple of situations where someone I had talked to for an hour and a half, had committed because I KNEW there was a high risk, and then that person was released within 72 hours. One of those ended up in a completed suicide. I was mad as hell at the hospital, the doctors, and the system. Again it comes down to resources, and laws and bureaucracy. Still - yelling at the hospital or the doctors in this case wont do one ounce of good. The system needs to be rebuild from scratch if we are to have any hope of making it better! The doctors couldnt have retained this person any longer - the 72 hours were up, and getting this person committed for long term psych care would have been an uphill battle. Besides this person really was intent on suicide no matter what, and quickly learned what not to say.

So, anyways - your points are well taken and very good of course. I just dont see how you plan to make the changes needed to the system?

Da Friendly Puter Tech

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