How do therapists keep boundaries regarding crises?

Just an abstract question I was wondering about. How are therapists supposed to keep boundaries regarding crises that happen outside of sessions? People often post on here about boundaries regarding email, texts and calls outside of sessions. But what about real crises, such as clients feeling suicidal or calling with other major, genuine emergencies? I suppose full time therapists might have 20-40 clients at a time, some steady, some rotating in and out (I don't know, just a guess). With that many clients, it doesn't seem too unlikely that several clients would be having crises during the same week, and that the therapist could be dealing with one or more crises most every week (again, just guessing). Does anyone know if this seems accurate?

And crises could be happening at any time of the day or night. I guess I'm wondering to what extent are a therapist's responses to a crisis likely to be based on their own needs to keep their boundaries? I know in real life it varies a lot and sometimes they are really generous and spend quite a while helping people during a crisis. How can they do that and not have their personal or family life interrupted frequently? I guess I'm also wondering what is the minimum amount of help that might be reasonable to expect in a crisis. Some people post about therapists doing lousy things like dumping them immediately after a crisis. Is that common? How are therapists taught to decide about how much time to give a client in a crisis?

I don't really have any answers except that most of the T's where i live do not offer crisis support as in taking calls during the night or weekends even.
My T isn't available after 5pm till 9am the next morning. She isn't available at weekends or when she is on holiday. She does generally get back to texts in the same day but it can be hours after i've sent it. Those rules obviously help her to prevent burnout but it sucks for me.

The first one I see has a message on her answering message that says if it is an emergency to go to the emergency room. But I also know she has gone to the home of another client who was suicidal.
The second one takes emergency calls home, but if talking for a few minutes was not useful, I imagine she would also suggest emergency room.

Well, being that I am in the midst of one and T was there for me Friday and Saturday this past weekend, I can give you my observations of it all and how I see he put boundaries in place. First off, he made sure that I knew that emails are for information exchanges and that he will not always respond to the emails I send him.. I tell him something, like I had a break down with MC.. He will say something encouraging like don't let the emotions you are feeling overwhelm you, and we can talk about it in our next session. So, when I am feeling overloaded I am more than welcomed to email and tell him something to get it off my chest.. He can choose to respond or not.

Calling outside of sessions- I call and leave a message with receptionist he generally calls back when he has time. Now this has something my is notoriously bad at! He will admit that he is terrible at returning phone calls, but in general if I say it is urgent he will try to get back to me faster than if I just said, please have t call me back. Also, I found that if I REALLY need to talk to him I can let the receptionist know that and they will be sure to let T know, instead of leaving a note in the box for T to pick up. When he does return phone calls, they are never more than about 10mins.. Friday when I was in crisis- our phone call was done right at 10 mins and I am pretty sure that is the longest we had ever been on the phone.. and I am sure that is quit purposeful.. He has said it with email and phone calls he doesn't necessarily want to bring therapy into those to forms of communication.

Finally, with texting.. This is rather new for me in terms of T. T just said to me today actually that he is letting his clients text him more in more as it is easiest way to get a hold of him, especially in crisis. He texted me Saturday morning after a tough day/night Friday and a promise I would be safe for the night. So, the next morning the exchange was.. How are you doing today? Me: better than yesterday. T: Good, I am glad you are feeling better very short and to the point. And when he first gave me his cell phone number he made sure to point out this wasn't to Text and say hey did you watch that show last night or something, lol. So, I see T put boundaries in place on the length of email, text messages, how much time he is on the phone and by choosing when he can return phone calls, emails, etc.

I think it depends a lot on the type of practice. T's usually try to balance their caseloads so that they don't have more clients who may be expected to have crises than they can reasonably handle. Or they may be in a group practice where different colleagues cover.

My T had told me that one of the most important parts of his practice was working with clients to prevent crisis responses by building up skills and constancy. So, for example, giving me his home phone number and urging me to call if I were feeling in crisis would allow him to intervene and prevent its escalation. It's a judgement call. And boundaries are important, too, in order to reserve interventions for extreme circumstances only. That said, he had to implement boundaries differently in his University job vs his private practice because he was bound by University policies in some cases, whereas he had more latitude in his private practice.

I think in many cases it isn't so much the T's personal boundaries that dictate responses, especially the policy of referral in crisis, but insurance carriers controlling liability.

My T and my pdoc are both available and pretty easily accessible in a crisis, and I certainly have had my share over the last 8 years. Rarely are these kinds of crises a surprise, particularly to my T as he sees me more frequently than my pdoc, so usually he is well aware that I am headed in that direction before I ever make a call.

If I need his help after work hours, I call his answering service and they relay a message to him. He usually returns my calls almost immediately. I rarely have to call after hours, but if need be, that is the procedure. Usually he just talks to me and assesses if I am safe or not. If I am, he gives me some time and suggestions for coping in that moment, and asks me to see him the next day. If he feels I am not safe, he usually asks to speak to my husband and asks me to go to the hospital if need be. My pdoc's system is very much the same except that the initial callback might be from a different pdoc in his practice as they take shifts being on call after hours (I suspect pdocs have far more "real" crises to deal with). Usually after the on call pdoc speaks to me, they contact my own pdoc and he calls me personally.

My T and pdoc are excellent in handling serious crises. They've stuck by me now for 8 years of multiple crises and hospitalizations.

I'm sorry it doesn't sound like the therapists in your area give you what you need

Thanks healed. That gives me a sense that a lot of them could have pretty routine practices about what they'll offer.

I've never been in crisis in the sense that I've never been suicidal or engaged in SI or anything like that. However, I have had pretty major life events happen during the time that I've seen T (death in the family, end of a long-term relationship, emergency surgery, etc). When something "big" happens, I send my T a text message and ask for what I want (a brief text exchange, a phone call, or an extra session). She will then text me back and (so far) she has given me what I have asked for. I would never text her during "sleeping" hours, but I have texted her at 7pm or on a Saturday or on her usual day off. She will usually text back within a few hours and will usually schedule a phone call or extra session within 24 hours.

Next week is my T's week off and she actually offered to do a phone session with me while she's on vacation! She made the offer because we had an intense and emotional session this week (processing childhood trauma). In fact, the last words I spoke in the session were: "so, my childhood taught me that every maternal figure in my life will abuse me or leave me." Her very next words were: "I will be on vacation next week." I think she realized how that sounded, and all of a sudden she was telling me she was there for me and she'll text me about scheduling a phone session. But, despite how tearful I was in session, I've been totally fine since then. When she texts to schedule the phone session, I think I will tell her to just have a good vacation and see me when she gets back. However, the OFFER meant more to me than I can express. I think the reason I have felt so good this week is because she did offer-- it made me feel like a maternal figure actually IS there for me now.

I'm not allowed to contact my T at all outside of sessions. School rules. However, I have managed to go around that twice. I had to go to the health center, say I was having an emergency and then someone else contacted her. But even without that, I wonder how they manage to keep boundaries. I'd be really worried about my patients all of the time. I guess they just have their own coping mechanisms to help let go of that.

T#2 wants me to call him or email him in a crisis so we can process right then and there what is going on and he can diffuse me. I have only emailed him and it was after 8pm. He always got back to me. Over the months I realized that he can not help me......bilateral tapping of the knees do not work, telling myself these are feeling from the past do not work and asking that triggered part what it hopes for me or what does it want does not work for me. So I wrote T off as someone who can help me and just the thought of that makes me feel so alone and even more desperate.

Now T#1 I emailed him late in the afternoon asking if he still had an appointment open because I have been a mess for 2 days and scared for my safety going into the weekend. He called me but I was driving. We arranged a time to call him as soon as I was done traveling. Some how there was a disconnect. Several hours later I emailed him upset and he emailed me trying to get me to call him again and he was going to call me in 15 min. if I did not call him back. I told him do not bother I did not feel like talking anymore. He sent another email requesting to please call him the next day. I did not respond until Sunday. This is the email I received in response.

Thank you for the email. Yes, I had been hoping for a response (even though you said you did not want to talk.) Yes, your response did matter to me very much. I have spent some time thinking about you, and sending positive energy your way. I hope the positive energy landed on you and not on someone else working out nearby...(I'm not the best shot.)

On Friday, I was waiting by the phone (office-to-cell set up) and jumped out of the ice-cream line when you emailed me. (No guilt there -please- I eventually got my ice cream. I just wanted to paint you the picture.) I'm guessing that you must have called the right number at 7pm on Friday but - understandabely - did not let it go several rings, and then you did not wait to leave a message. If you thought I was actually in my office then you were probably giving it just a few rings, thinking I should be able to pick up if it is right in front of me. Enough about the disconnect: We tried!

I hope that you are feeling better.

I love him and just knowing he is there for me really made me feel not so alone. I saw him the following week and processed what happened. He said it would he ok to call him if things got real bad like that and thanked me for not killing myself and was real happy I was sitting in front of him. This was the first session we hugged. I been with him for 10 months.

Out of the 5 t's I've had, only one was available in crisis. XT's voice mail had a feature where if you pressed a certain number after your message, it marked it as urgent and he would get back to you quicker. After figuring out that there was NO way I would ever consider a message of mine urgent, he got me to text him instead of voice mail. Part of that was to help with a speech impediment I have and a fear of voice recording. Text was the only way for me to get a very quick call back or even just a response.
The few times I texted were things like: "I am sort of in a bad place". He'd text back within a few minutes: "can I call you, or would you like to come in?" One thing about XT is that he was really good at diffusing a situation on the phone. When he went on vacation he would tell me "You can text me, because I know you aren't the sort of person to overuse it". I never texted him when he was on vaca...or on a weekend, there is no way I would ever interrupt his time off.

Over the years I have found that a crisis can be held off until the next work day, no matter how bad it seems at the time.

My therapists were all talk therapists so available during scheduled sessions. When I called on the phone for what I considered emergencies, they would listen and gently explain we would talk about it when I saw them next; not much that can be discussed on the phone that can help right "then" without the therapist present. If one is suicidal, that's not really in the purview of a talk therapist, that's a psychiatric or medical emergency.

My t cannot be reached in crisis due to the medical clinic rules he works for. Supposed to call a local crisis center if needed, but I know I'll never do that. I'd give anything to be able to leave a message for him without having to go through a nurse first. Just the simple act of letting him know what's going on would be helpful for me, even knowing that he can't get back to me. I write it in my journal instead. Not really the same, but for now it works. Plus then I can choose to share it with him next session. So because of clinic rules, he doesn't have outside contact with patients after clinic times.

My ED t, has much more open boundaries. I haven't been in crisis since I've been seeing her. Can't say that I'd want to call her anyway. She's said I can call her, leave messages, plus I have her email address. I'm so used to having such closed boundaries with my other t, that I'm not open to any of these with her just yet. Too foreign to me.

I meet a new pdoc today. She works with my t in the same medical clinic, so I know she'd hand me the same crisis clinic numbers that he did.

My T has a message on his voicemail saying to call the crisis hotline if having a crisis, and the phone number is provided. He tends not to answer the phone outside of business hours so that is one way he keeps boundaries. If the person is having a crisis in off hours, the crisis line is available. If a T does talk to a client in crisis on the phone and is worried they may harm themselves or others, the T can ask them to go to a hospital ER or can call the county mental health professionals team and they send someone out to the person's residence to assess whether they need to be hospitalized. I don't think my T has a lot of clients at any one time who are a danger to themselves or others. My T sometimes will come in on a weekend for a special session for a client who needs an appointment sooner than can be scheduled on a working day. So I think he does get his personal life interrupted sometimes--it's part of the job--but I hope it does not happen too often.

My t believes that being available for crises saves him time overall. If he can diffuse a crisis before it gets huge, then it's easier for him to help in session.

At least that's what he told me to get me to call when I felt I needed him. I've called him just a few times - when my mother went into hospice, when she died, and a couple of days after the first Christmas after she died.

I don't know how my T would handle a state of emergency as it hasn't happened. I called once to say I was in a crisis and needed an extra session, and he texted me (he knows I hate phone calls) to say he was trying to arrange an extra session and would let me know asap.

I don't think I would call my T if I was feeling imminently sui. I think that says a lot about me and whether I feel it's okay to ask for help. The most I'll do is text him and ask for an extra session if I'm feeling fragile.

When I was in crisis just a couple of weeks back my T called through to the mental health team and arranged for home visits in which they did that same evening, I am still having those visits now.

What do they do when they come to visit?