Trigger warning: discusses self-harm and suicidality.

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First, please know that hospitalization is not done lightly. No therapist enjoys sending their clients to the emergency room. This blog will cover some of the reasons why a therapist may make the call to send their clients to the hospital.

When beginning therapy, a therapist should go over informed consent.

This typically includes practice policies and limits to confidentiality. During this conversation, your therapist will explain that one of the limits of confidentiality is if the client is in imminent danger to themselves or to someone else. This means that your therapist is legally allowed to not keep confidentiality if you are a danger to yourself or to someone else. With that in mind, what does it mean to be in imminent danger to yourself?

The topic of self harm and suicidality comes up frequently in therapy.

In fact, researchers have stated that almost a third of young people attending youth-orientated mental health services and participating in longitudinal research report some degree of suicidal ideation (Scott, Hermens, Naismeth et al., 2012). This study included 494 people between the ages of 12-30. It is not uncommon for adolescents and adults to have thoughts about killing themselves. It is common for those with suicidal thoughts to not engage with therapy so the actual number of people experiencing suicidal ideation is higher than 32%. 

However, oftentimes clients worry about what they can share with their therapist without alarming them to the point of being admitted to an inpatient hospital (or as the younger generation calls it, “grippy sock vacation” named after the type of socks you are given to wear in the hospital that are anti-slip). 

There are varying levels of self harm and suicidality that your therapist is assessing in these conversations to determine the level of risk you are to yourself.

A therapist may ask their client questions like “how often are you thinking about hurting yourself?”, “have you thought about how you would do it?”, “what are the reasons you have not hurt yourself?”, “do you have access to medication/firearms/etc.?” 

A therapist wants to understand how much time their client is spending thinking about hurting themself, if they have a plan, if they have access to means of harming themselves, and if they have intent on acting on their plan. If the answers to those questions cause a therapist significant alarm and feel like the only way to keep their client safe is to have the client go to the hospital, then that is when a therapist will make the call to do so. 

However, when there is cause for alarm but not imminent danger there are efforts to keep clients safe before enacting a plan to go to the hospital.

Examples of these types of plans include: phoning a friend/family member, who a client and their therapist explain the situation to so they can be of closer support; it could mean more frequent check ins with a therapist; it might be developing a safety plan; or referring the client to intensive outpatient treatment (multiple hours and multiple days a week of treatment) or partial hospitalization (spending days but not nights in a program at the hospital). The same line of questioning and assessment is indicated when a therapist believes a person is in imminent danger to someone else.

If a client tells a therapist that they have plans to seriously injure or kill someone else, the therapist will break confidentiality.

Appropriate measures will be taken to keep both their client and the other person safe. In some states, therapists also have a duty to warn. This means that beyond helping their client be safe, they need to protect the other person in danger. This may include notifying police, warning the intended victim, and/or taking other reasonable steps to protect the threatened individual. 

The other circumstance that may lead a therapist to send a client to the hospital falls under the same principals; however, the imminent danger to themselves or someone else is not related to suicidality or intent to harm someone else.

In the case that a client has seriously impaired judgment that could lead to harm to themselves or someone else a therapist may deem that going to the hospital is necessary. This could be due to mania, psychosis, or something else related to mental health. In this case, harm to self could look like being so impaired that the person can not see the danger of running into a busy street, inability to care for oneself, or worsening symptoms that require immediate stabilization. Danger to others may look like a client having the inability to accurately assess a situation that could seriously harm another person, hallucinations encouraging violence that the person believes due to psychosis, or physically injuring someone due to a break in reality, just to name a few. 

Therapists do not want to send you to the hospital; however, if going to the emergency room is going to keep you safe then they need to make that call.

Ideally, your therapist discusses the need to go to the emergency room and you agree to go with a trusted loved one. Unfortunately, if you do not agree to this arrangement, the therapist does have the ability to petition for emergency evaluation due to the present danger of hurting yourself or others. If this happens, you would be escorted to the emergency room by law enforcement. This is a last resort option and only used when it is imperative to your health and life. 

The goal of hospitalization is safety and stabilization. Being in the emergency room will keep a client safe during a crisis in a way that the therapist cannot outside of the hospital. The hospital is also able to administer and adjust medication quickly which will help with stabilization of symptoms. As therapists, we know the hospital is daunting and uncomfortable. We wish the inpatient mental health system had a better set up and was more useful therapeutically. However, its main use is keeping clients safe when nothing else will.

If you are concerned about your therapist sending you to the hospital, have a conversation about it.

Tell them your concerns and ask for a review about the limits to confidentiality. Your therapist cares about you and is looking out for your best interest, and this includes having open conversations about suicidality, self harm, thoughts about hurting others, and symptoms like mania and psychosis. Most conversations about these topics will not lead to hospitalization and they are important conversations to have with your therapist so they can best help you. 

Reference

Scott, E.M., Hermens, D.F., Naismith, S.L. et al. Thoughts of death or suicidal ideation are common in young people aged 12 to 30 years presenting for mental health care. BMC Psychiatry 12, 234 (2012). 

October is Invisible Illness Awareness Month. In honor of this, let’s dive into what invisible illness means and work to understand how it impacts one’s lived experience.

Disabilities and illnesses can be visible or invisible. Or sometimes a combination of the two.

It can be ever changing depending on how the person is feeling or progressing in their illness. Both invisible and visible disabilities have struggles associated with it. Invisible illness is exactly what it sounds like, it is a medical condition that is not visible to others.

Examples of invisible illnesses include psychiatric disorders, diabetes, heart conditions, and chronic migraine.

Whereas, visible illnesses have aspects of the condition that other people can see and, therefore, understand that there is a medical condition present. Examples include, someone with hair loss related to chemotherapy treatment for cancer, the use of a mobility device for someone with chronic pain, or particular facial features associated with down syndrome. This blog is focused on the intricacies of invisible illnesses, however both versions of disability and illness have valid struggles.

Whether you have a disability or not you may have either thought or heard some of these sentiments before:

A 40-something year old gets out of their car, that is parked in a handicap spot and does not use a mobility aid: “That person does not need the handicap parking space, they are not even disabled”

This person has cystic fibrosis and struggles to breath when walking the distance though the parking lot.

A 30-something year old has to cancel plans due to chronic pain and dizziness related to their condition: “He could walk yesterday, but now he can’t? He just doesn’t want to hang out with us, he always cancels.”

This person has chronic fatigue syndrome and is experiencing a crash after pushing himself through the work week.

A 20 year old woman goes to the doctor complaining of increased fatigue, joint pain, and sudden weight gain: “You look fine and are too young to be sick. Just get more exercise and watch your diet.”

This person has ovarian cancer but will not find out for over a year due to being “too young” for ovarian cancer.

A 15 year old girl is not keeping up with chores and homework: “She is just lazy and does not want to put the effort in.”

This girl has ADHD and wants to do her chores and school work but her executive functioning challenges make it so that she can’t keep up with the demands of home and school. 

All of these statements are rooted in ableism and the lack of knowledge about invisible illnesses. Unfortunately, it is not an uncommon experience in the invisible disability space.

Having an invisible illness is hard. One of the reasons it can be hard is because people may not believe that you are sick and have a lack of empathy for your difficulties because they cannot see the difficulties nor experience them.

It can also be exhausting to educate others and advocate for yourself so people will believe you. However, it is necessary to do so in order to have your needs met and take care of yourself. People with visible disabilities also need to advocate for themselves due to ableism in society. The difference for those with invisible disabilities is you also need to “prove” you are sick. And once you do, people may frequently forget because your illness is out of sight and out of mind to them. Although, living with the illness you do not get the luxury of your illness being out of sight and out of mind as you live with it daily.

While having an invisible disability is burdensome, due to living in an ableist society, the ability to be able to “hide” your illness can be helpful when facing prejudice and discrimination. The problem is that people with invisible disabilities are often taught to lean into this and hide their disability, which tends to cause more issues than benefits. It is important to know that having an invisible disability is valid and it is not their job to hide their disability from others in order to make them comfortable. Having a disability is not something to be ashamed of; however, being taught to hide the illness (because it is invisible) can lead to feelings of shame or lead to minimizing their needs and experiences.

Invisible illness means it is not readily visible to others. However, it does not mean that it is not valid and not visible to the person living with it every single day.

Support may not be directed towards them because people can not see the need for support. This does not mean that they don’t need support. People may make accusations that they are  faking the illness or not understand the variability of symptoms day to day.

It is important that if you experience an invisible illness that you can remind yourself that your disability is real and valid. Coping with the struggles that come with invisible disabilities mainly includes believing in yourself and your own experiences. If you are able to validate your experiences you can better advocate for yourself, notice ableism around you, and take care of yourself both mentally and physically. The more you are able to communicate about your experiences, even if others’ cannot see it, the more likely you are to gain understanding from your loved ones and get support when you need it.

Becoming a parent can be an amazing experience for many. Like most amazing things, it is not without difficulties as well. In fact, the period after labor and delivery of a baby is a huge emotional and physical shift for parents.

While perinatal mental health issues can start during pregnancy, postpartum is an especially sensitive time for emotional wellbeing.

Here are a few diagnoses and terms you may hear about the postnatal period.

Diagnosis #1: The Baby Blues

The Baby Blues refers to the period of time between birth and approximately two weeks after birth. While this is not an official diagnosis, it’s important to mention because it describes a distinct difference in functioning. Onset may occur right after birth, or a few days after birth, peaking around day 5 of postpartum. During the first few days after delivery of a baby, there is a huge drop in hormone levels that your brain and body are working to cope with.

Understanding what trauma is can be important for healing oneself and is important to help cultivate empathy and compassion for others.

This article may be triggering to some as it gives examples of trauma and discusses trauma and PTSD. The American Psychological Association defines trauma as:

1. Any disturbing experience that results in significant fear, helplessness, dissociation, confusion, or other disruptive feelings intense enough to have a long-lasting negative effect on a person’s attitudes, behavior, and other aspects of functioning.”

Traumatic events include those caused by human behavior (e.g., rape, war, industrial accidents) as well as by nature (e.g., earthquakes) and often challenge an individual’s view of the world as a just, safe, and predictable place.

 2. “Any serious physical injury, such as a widespread burn or a blow to the head.”

We’re here if you need to talk.

A trained psychotherapist can provide a compassionate and nonjudgmental space to help you understand and heal from trauma. By exploring your experiences at your own pace, they can help you identify how trauma has impacted your thoughts, emotions, and behaviors. Using evidence-based approaches like CBT or somatic techniques, therapists guide you in processing difficult memories, managing triggers, and building resilience. Together, you’ll work to reclaim a sense of safety, rebuild self-trust, and move toward a healthier, more empowered version of yourself.

Orchard Mental Health Group is a large Maryland-based private practice with offices in Rockville, MD and Frederick, MD, providing affordable, accessible, research-informed counseling, assessment, and medication management services to children, adolescents, and adults.