Suicide, Self Injury and Hospitalization: Can your therapist have you hospitalized?

Allan N. Schwartz, LCSW, Ph.D.

Suicide, Self Injury and Hospitalization:
Can your therapist have you hospitalized?

Posting:

On March 7, 2009 someone posted this comment entitled:

"Distrust of Therapists"

http://www.mentalhelp.net/poc/view_doc.php?type=advice&id=3138&at=2&cn=91&ad_2=1&submit=I+Agree#ad8903

"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.<>

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.

Trust:

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.

Conclusion:

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

Source: MentalHelp.Net

Allan Schwartz, Ph.D.
Dr. Schwartz's Weblog

Negative Self-talk & Your Self-esteem

Self image is how we see ourselves, and how we think others see us. Self image plays a HUGE role in how we behave and feel.

Q: What is self esteem?

A: Self-esteem is our internal feelings and evaluation of ourselves based on our "perceived" self-image.

Self-esteem and self image are closely inter-related. And, are largely based on our feedback while growing-up (parents, peers, other important figures).

Fact: it takes about 20 positive statements ABOUT OURSELVES (the foundation of our self-image---self-esteem) to counter-act even just 1 negative personal statement!

Here's the difficult part: it doesn't take a continual repetition of negative statements from our parents, peers, and others throughout our childhood to cause low self-image-self-esteem...fact is, once we get a couple in our head, we can use them over and over again. Again and again we take those false negatives and repeat them unconsciously (completely unaware). It's like having a constant heckler with you.

Can counseling help? Most definitely. Negative self-talk is a big problem that most counselors are able to help with using a cognitive-behavioral counseling approach. We need to replace negative self-talk with positive self-talk we're willing to let ourselves accept. You can't draw on a chalkboard if there's an eraser following close behind. That's what negative self-talk is....it erases the good, and replenishes it with bad.

Fridays Readers Story

Anonymous said...

Hi
I'm 14 yrs old and have cut myself since I was 10 years old this wont be helpful in the slightest because I can't help others understand this as I don't even understand it myself. I think the reason I started doing it was because I felt I deserved it, I thought I was worthless. But then it progressed into an addiction, it sounds pathetic, I'm addicted to cutting myself.

I have stopped cutting for about three months before, and I started to feel bad about everything, stuff happened with my friends and I just got back into the routine of hurting myself again. Last year it got really and I couldn't think of anything other than cutting, even when I was happy I didn't feel I deserved to be so I'd cut myself. I have stopped pretty much now, not completely, I am trying to. The last time I hurt myself was last night, but before then it was about two weeks ago. It doesn't sound long I know. But as I was doing it around three times a day not that long ago I think I'm dong alright.

I don't go to a councilor although I have considered it before. I also suffer from problems with eating, not an eating disorder I just have a strange relationship with food and I have since I was young. My parents recently found out about the self injury. They told me that I could go and talk to someone if I thought it would help. I said no, as I didn't want to talk to them about it, I was ashamed, and I felt terrible. I'm sorry for this as it isn't helpful in the slightest.

xx

Mind Maps

Since my break Ive lost touch with others so tonight has been one of getting out and about the blogworld. I always lurked a little at Polar Bears Blog, he is a self described loner, chameleon, introvert & borderline personality disordered. What caught my attention tonight is his wonderfully creative Mind Map that he created to help with/explain his DBT (Dialectical behavioral therapy) contract. Anyway its worth checking out, I loved it.

Fridays Readers Story

Anonymous said...
I'm 19, i started cutting when i was about 14. it started as a peer pressure thing, it was 'cool' within my group of friends. My parents then moved me from America to Scotland, at 16 so my schooling was interrupted, I had to leave all my friends and relationships behind. This plunged me into a state of depression and I started to cut as a way to 'feel' the mental pain I was going to. every day, all up and down my legs.

My guidance counsellor at school found out when my well meaning friend found out and went to find my help. Instead of helping me my guidance counsellor thought it would be much more fun to black mail me into psychiatric help, and letting the entire school know and making things even worse. as I spoke to my shrink I learnt different ways to cope (I have since stopped cutting and live with my boyfriend and attend university, after getting my life back on track) but my guidance counsellor got bored hearing how well I was improving, and told my parents i was mentally deranged. they were hurt and confused, I took me a while to get back their trust, and it damaged my relationships with my siblings dramatically, setting me back in my recovery.

I just wanted to let people know, that even with people trying to set you back, when your ready to stop, you will. but only you can make that choice, no one can make you stop, eventually you just will, some thing else will take its place. don't let any one drag u down.

Treatments for self-injury

One danger connected with self-injury is that it tends to become an addictive behavior, a habit that is difficult to break even when the individual wants to stop. As with other addictions, qualified professional help is almost always necessary. It is important to find a therapist who understands this behavior and is not upset or repulsed by it. Call your doctor or insurance company for a referral to a mental health professional who specializes in self-injury.

Cognitive-behavioral therapy may be used to help the person learn to recognize and address triggering feelings in healthier ways

• Because a history of abuse or incest may be at the core of an individual’s self-injuring behavior, therapies that address post-traumatic stress disorder such as EMDR may be helpful (see Helpguide’s article on Eye Movement Desensitization and Reprocessing)
• Hypnosis or other self-relaxation techniques are helpful in reducing the stress and tension that often precede injuring incidents (see Helpguide’s article on Yoga, meditation and other relaxation techniques)
• Group therapy may be helpful in decreasing the shame associated with self-harm, and help to support healthy expressions of emotions
• Family therapy may be useful, both in addressing any history of family stress related to the behavior, and also in helping other family members learn how to communicate more directly and non-judgmentally with each other
• In cases of moderate to severe depression or anxiety an antidepressant or anti-anxiety medication may be used to reduce the impulsive urges to self-harm in response to stress, while other coping strategies are developed.
• In severe cases an in-patient hospitalization program with a multi-disciplinary team approach may be required

[From: Helpguide.Org]

Psychotherapy & Dealing With Teen Depression

Psychotherapy plays an important part in the treatment of a depressed teenager. For those parents who may think that being in a slump is something that their teen can just shrug off, here is where you may be mistaken. The despair and prevailing sadness that a teenager may experience from depression is a serious matter. If a parent were to simply wait for his or her teen to shrug it off, that parent could be waiting for nothing.

The important issue to remember here is that when a teen is suffering from depression this may not be the only problem he or she is faced with. In fact, a crucial problem that any depressed person may face is suicidal tendency. This is precisely why active help and steps in treatment of the disorder are vital.

Getting to the root of a teen’s depression

When a depressed teen is undergoing psychotherapy, the issues which lie behind his or her disorder are being addressed. A psychotherapist may want to talk with him or her about his or her feelings in different situations. By getting to the root of a teen’s depression the likelihood of it resulting in suicide is greatly reduced, if not eliminated. It is vital for a depressed teen to be in psychotherapy because it gives him or her a chance to air out the negative feelings he or she may be keeping inside.

This gives the therapist a chance to correct any misconceptions that the patient may have about him or herself, or life in general. Instead of leaving these misconceptions to brew negativity within your teen, he or she gets a chance to release them.

Talk therapy

Talk. Talk itself can be a very therapeutic activity. By having your troubled teen speak with a psychotherapist you are also engaging him/her in an activity where you are sure that he/she will not be isolating him/herself. When dealing with a disorder such as depression, any activity that can keep the patient from isolation or loneliness can be helpful.

Once the issues behind your teenager’s depression are addressed in psychotherapy, he or she may face a smoother road to recovery. Without the therapy, you are not certain that your troubled teen’s issues are being dealt with or just tucked away inside by your teenager.

Taking that first step to recovery

At first it may be scary for you and your teen to seek professional help, but it is an empowering step to take. By acknowledging that he or she has a problem and getting help, he or she is taking his or her first step to recovery.

[Link:Troubled Teens Info]

This Week At ...

Post Secret

Treatment Strategies

Self-injurious behavior can be reduced and eventually extinguished once the adolescent is ready to embrace alternative behaviors designed to promote healthier communication, self-comfort and genuine healing.

Psychotherapy — It is extremely important to work with a helping professional who has an expertise in self-injurious behavior or related disorders. Psychotherapy can provide a non-judgmental and supportive environment where self-injury can be processed openly and the meaning behind the injury can be explored. Trained therapists can provide safer, alternative ways to communicate, self-soothe and cope. The use of journaling, art therapy, relaxation techniques, visualizations, cognitive re-framing and affect management are all recommended and useful.

Appropriate contracts that encourage the teenager to write, draw, exercise and self-soothe before engaging in self-injurious behavior are more effective than contracts that demand the immediate cessation of the behavior. When the self-injury is severe, the teenager is unable to integrate strategies and abide by a safety contract or additional problems such as substance abuse or a threatening eating disorder are evident, inpatient treatment is often required.

In addition to working with a trained therapist some teens are able to utilize resources such as personal journaling and drawing, meditation, spiritual support and healthy self-injurious behavior substitutes such as physical exercise.

Psychopharmacology — When self-injurious behavior connects to untreated depression or anxiety, medication can be extremely useful. Anti-depressants can dramatically reduce the negative feelings and cognitions associated with the cycle of self-harm. Anxiolytics prevent the escalation of panic and generalized anxiety, which decreases the need for dissociation and self-injury. Providing a pharmacological safety net also may allow adolescents to process painful trauma memories without becoming flooded or overwhelmed.

[taken in part: *PRP Online]* Performance Resource Press

Tip #1

Prepare ahead of time for your appointments

I keep a special folder (bright colour so I won't lose it so easily) just for my psychiatrist and therapy appointments. I put anything I want to show them such as information about medicines I want to know about, programs I want to get into, or poems & journalling I wrote. I also put my list of questions I always have built up since my last appointment. Of course I bring my "Healing Calendar" where I chart my daily sleep, mood and medicine intake. By having this folder I usually get to cover everything I want to ask while I am with my doctor instead of walking out and 2 minutes after the appointment saying," Oh no, I wanted to ask.....!!!" Then have to wait another month or two before I can ask him.

[Facing Us.Org]

What Does Confidential Actually Mean?

Many professionals, such as doctors, nurses, teachers, psychologists, counsellors, social workers or youth workers offer confidential help and advice to young people. This means that you can tell them things in secret and they will not pass the information on to anyone else.

However, in some situations, the law says that they have to protect you by sharing this information with an appropriate person such as your parents, guardian or GP. This is called their duty of care.

Duty of care applies to people of all ages but if you're under 18 your well-being also comes under the laws of child protection.

This means a professional might not be able to keep all the things you tell them confidential if they think

• you might be suicidal


• you might accidentally harm yourself more seriously than you mean to


• you might harm yourself in a way that could cause permanent damage to your body


• someone is sexually or physically abusing you
  
• someone is harming you in some other unacceptable or illegal way.
  

If you plan to talk to a professional, and are worried about confidentiality, ask them about this before you tell them about your self-harm.

[taken from SH.Org.UK]

Self Injury Is Functional?

"We must understand that in the trauma survivor, self injury is functional. It always performs some deep, underlying function. Most generally, it’s an attempt to ward off worse harm."– David Calof

Tonight when I read this quote it was the first that resonated for me personally. I suffered a trauma at 11 and left for dead. After the hospitalisation & police investigations ended, my parents solution was to move us from the city & it was not to be spoken of again . Life was good, new home, school, family, horse and dog.

At 13-14 I remember I was in an out of control rage, against myself, family anyone near me. I was destructive, violent, smashing things, threatening others, running away being returned. I began carrying a knife (I still have that habit to this day) I liked that people feared me but I was also frightened of what I was capeable of. I had no way to control what I was feeling ,this rage, let alone understand it. It was raw & pure. I still don't know what triggered it. It alienated my father, who hasnt spoken to me to this day & confused my brothers who loved me.

My parents and the system inflicted school counsellors, psychiatrists, hospitalisations for violence and failed suicides. However I learnt that hurting myself stopped that anger, lessened it, dulled it. It stopped me reacting instantly (if that makes sense) .... It stopped the outward, out of control rage, it stopped me hurting others ...

Until I read that quote I never thought of it as functional or an attempt to ward of greater harm but in reflection thats what it was. At the time I thought I was the only one that was aware. Like the initial trauma, it was something that became not spoken of, secret, shameful. Counsellors all liked the change in me, (I stopped being emotionally honest and faked calm) they and my parents each patted themselves on the back and happily wrote me off as cured. My self destructive life had begun.

It occured to me tonight that after being hurt at 11, I then spent over 20 years hurting myself ... what an incredible price to pay...

ps... the quote is from Cavalcade has specialized in producing training videos for therapists and other professionals working with clients who have a history of psychological trauma.

Getting The Most Out Of Appointments

The hardest step, often is asking for help. Perhaps you've told a friend or a school counsellor. Though often willing they may not know how to help you. Talking to your GP is often a good starting point or phoning the mental health unit at your local hospital, many now have specific adolescent workers. Often we are afraid of being judged or decisions made that we don't wish.

Appointments with doctors, mental health workers, or other professionals may make you feel nervous. It’s easy to forget what you want to ask or to come away feeling confused about what was said. Appointments with professionals can be very short, and sometimes you have to wait a long time to get one, so it’s important to get the most out of every meeting.

You may find the following tips useful:

* If you make an appointment to see someone and you feel uncomfortable going on your own, take a friend or family member with you. They can provide support and help you remember what was said
* Before your appointment, write down all the questions you want to ask and make sure they've all been answered before you leave
* Write down the answers you're given. If you’re given the names of other people or organisations, make sure you write down the correct contact information
* There may be a number of support or treatment options available. Explain that you would like to know about all possible alternatives
* If something is said during the meeting that you don’t understand, don't be afraid to ask the person to explain what they mean
* Ask if there are any leaflets or other types of information you can take away with you
* If the appointment is with a mental health professional or counsellor you might want to see on a regular basis, use your first meeting to decide whether you feel comfortable with them and whether they are someone you think you could trust
* If you don’t feel that you are going to get on with a particular person or professional, go elsewhere. You have the right to choose. What matters is that you get the help you need
* Don't forget, you don't have to take any help or advice if it doesn't feel right.

The last 2 points are important to me. You are the consumer, Dr's are not Gods, and not all Counsellors suit all clients. If in anyway you are not happy, satisfied or confident in the person, then shop around but be clear with your motivations. I once didn't see a counsellor as all had told me 'This guy is tough but good, he can really help', I think I was totally scared it may work (if that makes sense) and I chose a woman who was nice but not really effective.

You need to keep thinking 'I am the most important here' but its hard at a time when you are emotionally exhausted and not feeling empowered. Being informed is one of the most important steps you can take both with SH and life in general. Take a friend who knows your needs, can help 'translate' or just repeat back what was said later, if this helps you.

[taken in part from: Self Harm.Org.UK

Friday Reader's Story ...

Gayle said...

From the time I was eleven years old til I was seventeen, I would cut myself. a lot. Sometimes it would be once or twice a week. other times when I couldn't handle the stress, it was everyday. It's been eight months since the last time I last inflicted harm on myself by means of cutting/burning.

The main reason is my best friend. It was a particularly horrible day. I was cooped up feeling sorry for myself and taking a negative action. I had taken about ten of my sleeping pills and had completely ripped up my arms with a steak knife. I needed to talk to my best friend just one last time. I remember it was taking everything I had to keep the phone up. She didn't answer her phone & when the voicemail picked up I was crying so hard. I don't think anyone could understand it. I kept saying. "I'm sorry Lizzie I don't know what I did. I'll miss you. I love you Lizzie. please forgive me."

I passed out, the next thing I remember, I woke up in the hospital strapped to a gurney. I was in shock. A few days later on my 17th birthday, I was sent to the state hospital. for therapy. I was there for nearly five months. near the end of my treatment, Lizzie had written a letter to my counselor stating that she kept the voicemail, and that I needed to listen to it..To see how it affected her. My counselor added into my therapy, for me to listen to the voicemail and write a letter to Lizzie telling her how I reacted upon hearing it. It completely tore me up when I heard what I put her through. I couldn't believe I would put that burden on Lizzie. I'm ashamed for what Ive done to my friends and family for being so selfish and stupid.

It's been a few months since I've got home, and I'm proud to say I've stayed smart in my choices. when I need help, I use my coping skills.[music.drawing.poetry.dancing] and if need be, I call my old counselor. I don't wish what I've gone through on any person or their families.

I had intended to keep my story to myself, but I guess something about your post made me feel like it was safe for me to share a small part of how I needed/got help. my piece of mind. Thank you for listening [reading] my story..x.

Gayle.x.

soo foo, so dak. <3>

Written: November 4, 2007