Will my Therapist send me to the Hospital?
Written by: Katie Lawliss, Psy.D.
Trigger warning: discusses self harm and suicidality
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 come 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.
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). https://doi.org/10.1186/1471-244X-12-234