Therapists as the gatekeeper to safety

I've never felt interrogated by my T. I entered into therapy recognizing that part of his job was to deal with my safety on some level. I also desired his help. My therapist has demonstrated an immense amount of discretion with regards to my self-harm and suicidal ideation (which thankfully has not been an issue since finding proper medication). However, with my pdoc, I didn't always disclose honest answers when he ran through the checklist. I know how to fly under the radar and I didn't trust him to necessarily have the same discretion. I have fudged the questionnaires with many a professional simply because I didn't want to deal with them.

I guess I don't see them as gatekeepers - I'm not entirely certain what that means. I mean, I've always just thought of the safety thing as part of their job description and if a client doesn't want that interference than either they keep it to themselves or they don't enter into therapy.

Woah! I wasn't judging. And I certainly wasn't judging "all people here." That is your take on it. Please don't take it as such. I apologize if my words offended you; they weren't meant to. The point is that there is a vast difference in the range of difficulties people deal with. Perhaps I shouldn't have use the word "many," but to scold me over that is a bit much.

I remember during a serious medical crisis a young resident was attempting to pressure me to have a medical device implanted in my chest (pacemaker) following open heart surgery--I was having severe arrhythmias (heart rate down to 28-30) and they were worried I was going to code. I wanted to wait because I felt that the "irritability" of the electrical system of the heart was caused by surgery. I could see her agitation and irritation with my refusal to sign the permission to do surgery paper. She kept pushing and I kept saying I wanted to wait. She had the nurses bring in the code cart and sat it at the end of the bed. I told her that was good planning. She got ticked and pushed harder. She said, "You need to have this procedure done tonight." I asked, "Well, what's the worse that can happen?" She responded, "You'll pass out and if your rate doesn't return to a normal rhythm, you'll die." I said, "But I'll be passed out and I won't feel anything, right? I mean I'll just quietly slip away. Don't knock sudden death, doc. It's a pretty easy way to die." Her eyes opened wide, her mouth fell open and then she clamped it shut and walked out of the room.

I get professional people's need to "save us from ourselves", but sometimes we don't want to be saved. Sometimes it's a good thing that we get to make our own decisions. Now I get it that this doctor felt like I was NUTS, but she couldn't argue with my calm, rational and reasonable approach to how I felt about having a pacemaker placed in my chest before I felt there was a need to do so. I was lucky that I got to make that decision because no one could label me as a "insane" person and could take away my right to consent or not consent. I do feel that there are many times that psychiatry and psychology runs rough shod over mentally ill people, labeling them incompetent and making their decisions for them. And I also get it that some people are so glad that someone intervened and insisted on them being "sectioned" for their own good. Or when the courts insist that a person cooperate with treatment and they find a light at the end of the tunnel or their plans to commit suicide is thwarted. But it's hard to tell who wants this kind of "assistance" and who would prefer to go their own route. But the good thing is that people can, if they're able, make the decision who and what they tell professionals. If I want help working through suicidal thoughts and the therapist I'm seeing is a calm, rational and unflappable person, then I can have the conversation. If I realize that he/she is bound to react with alarm and self-protection, then I'd probably keep my trap shut!

****MAJOR TRIGGER WARNING*****

I don't know who saw the PBS special on the young woman in Europe who contracted with her psychiatrist to allow her to have the right to die due to chronic and debilitating depression. It was a very powerful program and really made me realize that sometimes people truly don't want to live that way any longer and death is preferable. I know that kind of thing will never be allowed here in the United States, but it sure pointed out that "our" way isn't always the only, right way. Just sayin'

which is exactly the reason why I won't go into proximity of a shrink. I prefer to self-destruct my own way, when it comes to it, by my choice. Not being broken and destroyed "for my own good". My life, my mind, my choice.

If I wanted others to make decisions for me, I'd move to North Korea.

Thank you. You do a very great thing.

I think using such language as "interrogate," "inflict" and "intrusive" is already making a judgement that casts the subject into a b/w framework that is not reflective of the reality of practice. Therapists do have an ethical responsibility as well as a legal one. Whether the ethical mandate arises from self interest or other interest doesn't really impinge upon the actions taken, if the actions are appropriate standard of care otherwise.

The primary way that therapists can discharge their ethical mandate at the lowest possible level of engagement is relative to the degree of trust and communication that exists with the client. I think this is where professional competence and experience really come into play: a therapist with less experience, both with crisis and practice in general, is likely to have less ability in being able to read a client/situation. A client who is extremely guarded in communication is much harder to read. Both contribute to greater unknowns and a higher level of potential threat. Under those circumstances, a therapist is more likely to take action.

My own experience was that I could become very destabilized temporarily. And my T told me that early in therapy he worried about that because it was a difficult balance to achieve both progress through pain, yet keep stability in an outpatient setting. But my open communication and ability to stabilize myself, together with his experience and the confidence gained from that experience, allowed us both to trust in and contribute to our joint ability to contain the powerful emotion engendered by therapy.

I did use the terms I found accurate. They don't get to save me from myself. It is no one else's right to do so. I have means and plans to keep my autonomy at any cost. I don't tell them many things and I will keep working for autonomy at any cost for those who want bodily integrity. I would never try to stop someone who wanted interference from getting it -it is those who do not want interference in their choices that bear on only themselves that I believe should have choice and freedom. I don't want their intrusive ethics anywhere near me.

I think if a client addresses the issue then I would expect t to comment. Like if I tell my t I consider taking heavy drugs for recreation and want to know if it is good for my health, I'd expect her to say it's dangerous rather than giving my high five. But I don't think it is Ts job to tell he what's good or bad for me if I don't even bring it up or ask.


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I would find their statement or indication of approval just as off-putting as their disapproval. I would never allow them to high five me for anything. Not their place to do so. I don't look for them to approve or disapprove of my actions. It is absolutely, for me, not their place to do so.

I don't envy therapists the balancing act that he/she is faced with. It is daunting! How does one determine whether or not one wants "interference" or whether one wants total autonomy to do as they please? I say this with the perfect understanding that no one, not the therapist, the lawyer who acts in the client's behalf, the family, the person themselves, always knows the true answer to this question. Heck, I haven't always known the answer for myself sometimes. But I do admit that I'd rather err on the said of "non-intervention" than on the paternalistic response of "I know best what the person needs or wants".

I tell them. I don't think it has to be all that hard all the time. Perhaps from time to time it might seem that way to one of them. I agree I certainly want everyone who comes into contact with me to err on the side of no paternalism and non intervention. Death is not, in my opinion, the worst thing that can happen.

Couldn't "no" just be taken to mean "no"?

Of course it could; that's pretty basic and accepted. But I don't know about you, but I've talked to enough people who stated emphatically that they were READY and didn't want anyone interfering, making any interventions, being do-gooders, etc. etc. and then . . . . a day later, a week later, years later that same person has the conversation with you saying, "I'm glad so-and-so intervened. I'm glad I wasn't able to do it. Life is good and I didn't really want to die." I was confused, mentally unbalanced, feeling hopeless and abandoned, adrift, psychotic, manic, severely depressed etc.

But then, I also know very well that there are the people who let you know in no uncertain terms that the decision that was made to make sure that he/she was "protected from themselves" was wrong, obstructive, restrictive, paternalistic and a soul killing intervention. Who can say for sure what the right decision is in any one situation????? Anyone who says that he/she knows for sure the right course of action is fooling himself/herself--be that therapist, family member, primary physician, policeman, lawyer, whatever. Sometimes the assessment that one makes is the wrong one and living with that decision is difficult . . . not for everyone, but it is for me. Sorry but that's how I see it.

I didn't read all 4 pages.

However, my initial thought was that the OP was intentionally vague in order to garner the support of others....i.e. be vague so that you get support for your unsafe behavior.

I don't think this would be a thread about juggling chainsaws. I think that perhaps you want support for harming yourself.

Sorry but no can do.

No. Not at all. You have misinterpreted my entire point. And I assure you, I have absolutely no desire for your support in any way.

I'm curious how you came to this conclusion. Do you agree that people who are mentally ill are unable to make their own decisions about their care and treatment plan if it doesn't agree or fall in alignment with his/her "professional" treatment team? Do you believe that medical personnel/mental health professionals are always better able to determine what the best course of treatment is for an individual client? Has there never been a time that you have disagreed or thought differently than the professionals providing treatment? Just curious, because your post seems pretty conclusive and judgmental about ADULTS ability to make informed and individual choices about what is or is not acceptable to them in regard to mental health interventions. It's NOT just about what the physician, mental health professional, family member BELIEVES is the right course of treatment. Even people with mental illness have a right to decide how and what should be done. And it really isn't okay to say, "but he/she is suicidal, schizophrenic, bipolar, BPD ect and he/she doesn't really have the capacity to know what he/she really wants or needs." How do you prove that? How can you really know? Is the fact that you keep the person alive the only result that proves you were right? I don't think so. It is the quality of the other person's life and NO ONE gets to make that determination but the individual everyone is making the decision for! And sometimes, even years after the save, the person still doesn't see the value in the decision the system decided to make for them. That is as awful to me as the decision one makes not to intervene and the person ends his/her life and cuts off the opportunity/possibility for something wonderful. It is not a clear cut decision either way.

I don't desire safety - I desire death. T tries to keep me safe - I do not.

I do find it interesting that the role of therapist got itself so positioned. It is that positioning that I was talking about.

I don't see it is intrusive if a client brings it up in therapy. I in fact think it's just common sense if a person tells me they are about to do anything dangerous or harmful, I won't just ignore. I wouldn't interrogate people asking if they are about to harm themselves but I sure would say something if they do share. I don't see it as any different with therapist. Sometimes sharing ones struggles or potential plans is a cry for help.

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While I think ts care about the safety of their clients for legal reasons. Many ts also get into the field because they are caring and compassionate. They worry about their clients the same way they care about the other people in their lives. I work with doctors and ts who have lost patients to su. It devastated them not because they were legally responsible. But that the missed something our did something wrong that the person was unable to reach out. I have seen doctors cry because the felt the failed a curvy and they really cared. I know my t always cares. She also knows that will and have reached out when not safe because I have a reason to live.

What - no poll?

I don't think someone else caring trumps my autonomy. I am not just talking about suicide but rather any sort of safety -i do not believing in turning over to those guys. Their alleged caring or not does not change my stance. That their idea of care or belief they care then allows them to run roughshod over autonomy of clients is what chills me to the bone.

And I know-but a poll on this would have run rampant with criticism at the poll choices.

I guess I'm not entirely certain your stance. :-/

Like I get you not wanting them discussing your safety or commenting on it and I agree that a person ought to be able to have autonomy with boundaries. But, for me personally, I invited my T into that world. Yes, he asked me about safety stuff, but I've pushed him back on topics before and I've just flat out not given honest responses to other healthcare professionals. In the end, I decided I wanted my T to be part of it and I haven't been disappointed in his discretion.

Perhaps you're talking about the fact that one would feel the need to give a dishonest answer? That they shouldn't even ask?

I'm just trying to understand.

No, I don't think a t can keep anyone safe. It's still the person's choice. If a person wants the t to keep them safe, then fine, but it's still not really the t. It's the person willing to give that to the t, willing to listen to the t, willing to do what the t asks. I've never had a t ask me questions about safety unless I've brought it up myself, except on the inpatient intake form. When I didn't want any intervention at all, I just didn't speak about what was going on. I had a doctor try to commit me bc of my weight (anorexia). Idiot! Thank goodness my pdoc knew better. My safety is up to me and I like it that way.

Shhh! LOL