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Summary
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A reader with a history of self-injury wants therapy but fears that disclosure could lead to hospitalization despite no current suicidal plans. They ask how therapists distinguish self-injury from suicide risk and explain confidentiality.
The response describes confidentiality and safety decisions as nuanced, with obligations varying by U.S. jurisdiction and the therapist’s assessment of risk.
It encourages discussing reporting policies and informed consent directly with a prospective therapist, and exploring clinicians experienced in Dialectical behavior therapy (DBT) and self-injury rather than assuming that disclosure always leads to the same outcome.
Question
Reader · Identity withheldI’m a 27-year-old woman who has struggled with self-injury (cutting, burning) since early childhood, following physical, mental, and sexual abuse. I want to seek help but have concerns. If I tell a therapist about my self-harm, are they required to report it the same way they would for suicidal intent?
\nI attempted suicide 5–6 years ago, and while I’m depressed and struggle with anxiety, I have no plans to attempt suicide now. Still, I worry that these factors combined might lead a therapist to hospitalize me. If that’s necessary, I’m cautiously open to it, but I’d rather avoid it if possible.
\nWhat are a therapist’s obligations when it comes to reporting self-injury? I know you may not be able to answer everything, but please—I'm scared and don’t know what to do. Thank you.
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Answer
Mark Vigil Dombeck, Ph.D.There isn’t a cut-and-dry answer to this question. Self-injury falls in a sort of gray area between what is reportable and what isn’t. I should define \"reportable.\" To be very clear, what I have to say here applies to the United States of America only; other countries will have different rules in place.
\nIn most U.S. jurisdictions, psychotherapists (at least the licensed ones) are mandated by state law to report certain behaviors to responsible authorities (e.g., the police, physicians, etc.).
\nThe exact definition of what is reportable varies from state to state, but generally, it has to do with the state’s desire to prevent people from harming themselves or others. Abuse of other people is almost always a reportable issue, no matter what age the victim may be. Homicidal intent is always a reportable issue, and so is suicidal intent.
\nThe idea is to prevent people from harming themselves or others. With regard to stopping abuse, the intent is to prevent both physical and emotional harm to others. However, with regard to suicide, the assumption seems to be that no sane person would ever want to kill themselves, and the standard is that there is never a time when it is legitimate for someone to want to harm themselves. No exceptions are made for terminally ill people who would like to avoid pain and suffering, etc., unless this is specifically provided for by other state law (e.g., the State of Oregon may have different rules, but I’m not sure about that).
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Licensed psychotherapists generally also have a legal and ethical duty to protect their patient’s privacy. Psychologists can invoke a legal privilege to not reveal what their patients tell them in confidence, much like lawyers. However, the state’s interest in preserving life and preventing abuse trumps the right to confidentiality. Psychologists who do not report when they are supposed to report can face legal sanctions. Most professional groups have designed their ethical policies to match state law, so there are few cases where a profession’s ethics would compel them to take a stand that the state would consider illegal.
\nAll of these issues should be explained to patients by therapists during their first therapy meeting during the part of that meeting where informed consent takes place.
\nThis sort of stuff should be documented in writing, and many therapists like to get patients to sign off on a paper saying that they understand the rules. Of course, these issues of what is safe to talk about and what isn’t also need to be discussed for as long as proves necessary to make them clear in the mind of the patient.
\nSelf-injury is a very different animal than suicide, but this distinction is not well understood by all therapists. Especially new and relatively inexperienced therapists, and therapists who are feeling the need to be more rather than less cautious, may mistake self-injury for suicide and pull the trigger on reporting. If you think about the situation from the perspective of a therapist, the temptation to report when someone tells you they are engaged in a risky and potentially lethal set of behaviors such as self-injury is very high.
\nThe therapist has a duty on multiple levels to create an atmosphere of safety for the patient. Sometimes patients will act in ways that are impulsive and dangerous, and it is the therapist’s duty to try to limit those behaviors as much as possible, not unlike a parent’s duty is also to limit a child’s impulsive behavior. I don’t use this comparison lightly; therapy in some cases is equivalent to emotional re-parenting, and reigning in is necessary to promote the patient’s ultimate health, and not their momentary comfort. The therapist has no way to know what constitutes safe self-injury and what doesn’t. If the patient is new to the therapist and there is no track record, the therapist has no way of knowing if the patient is likely to be under or over-representing the degree to which they are able to keep themselves safe.
\nMany people who self-injure will report suicidal ideation and other signs that are consistent with an elevated suicide risk. In sum, the therapist has to feel comfortable that the patient is not actually in acute risk of harming herself, and there is often no basis for making that judgment other than one’s gut and the word of the patient, which isn’t worth much when there is no pre-existing, long-standing relationship to base a judgment on.
\nThe therapist simply must make a decision and then document her reasons for why she has made that decision so that in the event that she is wrong and an actual suicide occurs, she is able to justify her decision to the authorities who will investigate that death. It is very tempting to just be cautious and send people to the hospital at the first sign of danger. It is also tempting to restrict one’s practice to not work with people who self-injure, as this puts you at unnecessary risk of a serious career-threatening lawsuit.
\nWhat I’m saying is that it takes serious balls and serious compassion to work with patients who self-injure because of these legal risks, and people don’t generally appreciate that and should. Every therapist faced with self-injury would report if there weren’t serious therapeutic downsides to reporting. Patients who are reported on will inevitably feel betrayed, even if they logically can understand why the therapist chose to report. This will generally make further therapy difficult or impossible, and sometimes patients will generalize and feel that they cannot trust any therapist (not just the one who reported).
\nSometimes temporary hospitalization is really necessary for the simple containment and medication reset it can provide, but the cost of that is very high indeed if patients lose trust in the safety of the therapy environment. The need to preserve a fragile trust, which is in the long-term healing interest of the patient, is the reason why more reporting does not occur.
\nThere are many therapists out there who are comfortable with the ambiguity and the risk of self-injuring patients, and also a bunch who aren’t. The only way to know about what your therapist’s philosophy is about self-injury is to ask, ideally during the first session or two you have with her, before you become an official patient. You don’t need to admit anything to ask, \"What is your reporting policy on self-injury?\" and if you don’t like what you hear, you can walk out the door before you have agreed to enter a therapy relationship. This is a fluid boundary (as to when you become a patient), admittedly, but it will never be as loose or gray as it is during the first getting-to-know-you session.
\nI recommend that you specifically seek out and work with a therapist who can offer you Dialectical Behavior Therapy (DBT) for several reasons. DBT is specifically designed for people who self-injure, so by definition, a therapist who offers DBT is comfortable with working with self-injuring patients and understands the distinction between self-injury and suicide. DBT is known to be helpful for self-injuring patients for another reason (and you want to do something that has a good chance of helping).
\nDBT has protocols for working with suicidal and self-injuring patients, so ask the therapist to go over them with you. There will be rules. For instance, you will be encouraged to call before you act out something suicidal so that you can work out a way to avoid doing it. If you self-injure with suicidal intent and then show up later to mop it up, the therapist will help you but also likely provide a consequence, such as your not being able to go back to therapy for a while. You need to know what the rules are with regard to whatever form of therapy you go to, so I strongly encourage you to ask.
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