It’s Your Turn #1 Response July 6, 2015

2) To what degree is a therapist obligated to intervene should he or she decide that the patient’s mental state renders him unable to control him or herself and act in his own best interest?

To the first point, one hopes that a skilled therapist’s probing, understanding, listening skills and empathy reduce the pressure to ‘act out’ and create an ambiance conducive to ‘talking things out.’ Here is where exploration and discussion of past traumatic experiences and inner motivations such as a poor self esteem, past history of trauma, body image issues, family-of origin issues and unresolved conflicts belong. Encouraging youngsters to put their feelings into words can be remarkably therapeutic. Can talking things out prevent self-injurious behavior? Yes; but, unfortunately, not always. That’s where clinical judgment comes in. So for example, if the acting out with the teacher was an attempt to turn the tables psychologically on someone who sexually abused the patient earlier in life, talking that trauma through may not only stop the patient from acting out, it could form the basis of a powerful therapist-alliance: the most desirous outcome possible.

To the second point, if the patient is too impulsive or psychologically disturbed to respond to the therapeutic dialog that reassures the therapist that pressure to act out is relieved, the therapist has an obligation to intervene in the patient’s life. Warning the potential victim of the patient’s schemes has a role. So does involuntary institutionalization if the patient is completely out of control. Sometimes a patient is literally pleading for restraints (limit setting) to keep her safe from self destructive behavior, and needs her therapist to be strong enough to take matters firmly in hand to prevent harm. A young woman like this could easily be under the influence of drugs or in a hypomanic state where talking things out would not be enough to prevent acting out.

I urge therapists-in-training to get families involved right from the beginning as a parameter of starting treatment, and make it clear to the patient that requests for confidentiality will be honored up to the point that no one’s well-being is in danger. After that therapists need do everything in their power (including institutionalization if necessary) to keep a situation from deteriorating. It’s the therapist’s job (not the patient’s) to set the ground rules for treatment.

I’m contacting the “winners,” although everyone deserve kudos for such thoughtful responses.

Great job everyone. We’ll do this again soon.