Live with Evan

All right, everyone, welcome to this Cadre livestream. My name is Evan Lieberman. I am a licensed mental health professional, licensed alcohol drug counselor, and I'm here to answer your questions about mental health addiction therapy. You could pretty much ask me anything. I may not be able to answer everything, but you could certainly ask. But for today, I found a really good question that came to me through my email, and I thought it would be a great topic for today. And at any point, feel free to chime in and ask any questions and I'll see if I could answer them as much as it pertains to this topic or, I guess, anything else.

So, yeah, why don't we just dive right into the email and see where it goes from there? So this person writes, I'm an admin on a Facebook group that started as a fan group for a mental health podcast, and we try to make it a safe space for folks who have mental health issues and want to talk rent and not alarm their friends and family. But I'm asking about Si, and she's referring to suicidal ideation because we had a family member post today that he's been afraid to discuss Si because he doesn't want to be automatically admitted to a hospital because it will mess up his career.

And there are quite a few things in this email that are really telling about where we're at really culturally when it comes to suicidal ideation. And talking about it can be really difficult. And she is talking about being on this platform, not this platform, but being on a platform that's public and talking about suicidal ideation. And people dance around the topic for a few different reasons. And again, I think it's a double edged sword as to why we need to maybe be a little bit careful and then on the other end, why that actually can be problematic, to not talk about the issue directly.

So that's one thing we'll be talking about. But the other element of this is, when I am seeking access to mental health services, what fear do I have going in? Especially, let's say, I have more severe depression or suicidal ideation? Am I going to be admitted to the hospital if I say the wrong thing? And this is such a common question, and that's why I wanted to bring this up, so that you all know, as a mental health professional, what are my obligations to break confidentiality and to have to recommend and essentially call emergency services to get you admitted to the hospital.

So I think it's important to know that. So we're going to go over that as well. We'll talk about some of the ethics around mandated reporting. But first, let's go into the first issue that this, I always want to say, caller, because I feel like I'm on a radio show, but this individual reached out to us about so the stigma of suicidal ideation and on like, social media, or any kind of media for that matter, it's touchy. And a lot of the algorithms pick this up. Right. And they will a just not allow you to talk about it on certain platforms.

Or they're really, you know, they may not say it outright, but they really downgrade that content. Or, you know, so they either, like, don't allow that now. So people end up dancing around it because let's say they're making content or they want to ask a question. Question. They use, like, code words, right. And we kind of get trained, not literally, but it's kind of a known thing so that people don't use that word suicide. Right. And it kind of gives me, like, anxiety a little bit. Right. To talk about those things because I've kind of been trained to fear that.

I've been trained to, you know, fear that topic because one is a therapist. You know, there's always liability. All right, I gotta be careful because if some, if I say the wrong thing and someone does something to hurt themselves or other folks, you know, I could be liable for that, right. And then other people are afraid to talk about because they're afraid of getting their social media pulled or being censored. So we use these code words, si, one of the biggest ones you'll hear on, like, social media will be unaliving, saying, unaliving myself, that's another big one.

So I think one of the reasons for that, and it's not necessarily for bad reason why they do it. It's not for ill intent, but it's because there have been instances, if you go to some dark places on the interwebs, there have been sites and groups that have really attracted and targeted young and vulnerable people that have literally encouraged people to commit suicide. Young and vulnerable people. And folks talk about. Right, their struggles, and then they actually teach each other how to do this and encourage each other to do this and positively reinforce this.

And it actually worked. Right. And I don't know, like, the deepest intentions of the people who started. There's actually some been some good articles and, you know, stuff. I think there was one from the New York Times on the Daily podcast that did some investigation to try to find, like, the people who started this. You know, it's, it's interesting if you want to check that out. But, you know, and another thing is bullying. I mean, there have been a lot of teens, and teens are, like, much more vulnerable than they've ever been to this because of social media, most likely.

But a lot of online harassment and bullying were, like, people have outright told people you should go kill yourself. Right. And often they do that. Right. And so that's why I think there was this big pendulum swing to be like, we really need to censor this to make sure that this stuff doesn't happen. So that makes a lot of sense. And I think the other reason, too, is this could be a triggering topic for a lot of people. However, I also think that it's important that we don't dance around the issue and further stigmatize it.

And this also goes for, like, self harming behaviors like cutting, burning, which are very common forms of self harm, as an unhealthy coping skill that people use when they're feeling overwhelmed. And so the more we dance around it, we can't talk about it and we can't give helpful, reliable info. I mean, luckily, in the confines of this app, it's a safe space to do that. It's not fully public. And even if it is, that depending on the context, for example, myself as a therapist, as someone who's trying to educate, someone who's trying to help, you know, that probably shouldn't be censored.

And we shouldn't have to dance around that because a lot of people need help with this. I mean, this is a very common question, again, people reaching out for help. And that's got to be the hardest thing, you know, for when I talk to other creators who are mental health creators, and then people want to reach out, like, you may be the only access to, like, mental health. I don't even want to say services. I don't even know what to say. But their only exposure to, like, a mental health professional.

And, you know, when you see that on a public, you feel like you want to reach out because maybe you don't have resources or support elsewhere. So a lot of times we get people who reach out or on, like, various live streams, you know, people saying that they want to kill themselves. And, you know, as a therapist, like, we have to be really, you know, I gotta be really careful, especially engaging with people who aren't my clients. And it's really difficult. Right. And, you know, like, for, like, ethical reasons, I can't engage in that with just the general public, but I can, you know, and what I try to do in these situations is talk in generalities, right.

About, hey, here are some things that you can do that often get recommended that are evidence based practices for folks who are struggling with suicidal ideation or self harm, and hopefully that helps you and encouraging folks to go and get support from others, let's say, in the community who are following, you know, mental health type stuff, you know, or in this context as well, if we're building a community here and others who have been through it, I mean, that could be one of the most powerful things outside, maybe even equal to more so than just doing therapy.

Right. So, I mean, both are absolutely great, though. So, yeah, I mean, we unfortunately have to dance around those issues. Now, transitioning that a little bit into how that looks in the therapy context, especially when you're starting therapy, because it seems like most people know that if you tell your therapist, I'm just saying this in generalities, you tell your therapist, I'm suicidal or any emergency, if you call 911, you know that it is possible that your rights can be taken away temporarily.

Right. So as a therapist, I have, you know, as a mandated reporter, I have that ability and obligation in certain situations that may lead to you getting your rights taken away. And I know that sounds like super intense and it's not always good to look at it that way, but literally, that's what's happening. And that is why I have to take these things extremely seriously, because no therapist wants to do this. I mean, it's literally among our least favorite activities to do as a therapist. And we want to avoid it as much as possible.

But we also need and want to make sure that someone is safe and not a risk to themselves. So this is not something that we as flippant and it's not something that, you know, and I try to explain this to people because I think it's important that if you're reporting to me that you have ideation, that doesn't necessarily mean that I'm going to press the button and two big guys are going to come, you know, and haul you away. Right. I kind of joke with clients a little bit at the beginning when I first meet them about, here are the limits, confidentiality.

You know, I am a mandated reporter. Here is what that means. And here are the situations. And I don't think all therapists really do this to the degree in which they should and which they're reasonably expected to do because it's like going into any relationship business deal. I mean, you want to have all your bases covered, you know, like, okay, here are the financial policies. And that's an ethical thing, too. Here's what that looks like. Here's what this looks like with your insurance. Here's what this looks like.

If they don't cover it. Here are the limits of confidentiality. Here's what HIPAA means here. I need a release of information. So these are like the things I go over with clients in the first session before we do anything. It's informed consent. So you need to know what you're getting into. And once we do that, then you understand that if you agree to that, you are signing in the paperwork, too. But once that happens, then we could go ahead and move forward and hopefully never think about it again.

And hopefully it's never an issue again. And I would say 95% of the time, it's not an issue right now. It brings up an interesting ethical conundrum. And that is so let's say a client tells me something in confidence, but it presents such a risk that I then have to call emergency services and try to have them admitted to the hospital. Right. So that's the thing is, I don't want them to be afraid to tell me when that is the case. When that happens, I don't want them to be dissuaded to do that. But at the same time, you know, I have to do that.

Right. So it's like this conundrum of, I want you to tell me, you know, if you're feeling, like, really unsafe and you have a plan and all that, but I don't want to take your rights away, because that may not be what you want. You may not want to go to the hospital. Why would you? It's not about want, but it's about need. In that moment, it's hard to wrap your head around that. I may need to do this and go to a hospital for three days or five days or whatever that may be. It's not fun. It's not anyone's idea of a vacation by any stretch of imagination.

So that's why I'm extremely clear. Right here is what I have to report, and here's what I don't. One of the things I will literally say, I'd be like, look, and I'll just say this now. It'll give you a better understanding. But I say, all right, everything that you and I say and do is confidential. Your insurance company does have access to some of these records. Some I am able to keep private. Therapists often keep two sets of records. One like, that's not public, but one that could be seen by, like, let's say an insurance company or if I'm sending this to another provider or a probation officer, whoever needs to see this, right.

So, you know, this is, everything is confidential, and I can only share this information if you sign a release of information for that person, institution, whoever. So that's one limit of confidentiality. The other is if you are a risk of harm to self or other people. Right. Duty to warn. So, and that only means if you tell me that I have a plan to hurt this person, I have to warn this person and emergency services, because there were cases with confidentiality where therapists didn't do that. The client actually went and hurt the person and then it became a law.

This is in California. Don't quote me on this. I don't even know why I brought that up because I can't remember exactly. But, you know, 30, 40 years ago, this is something that happened and then became law. So understanding that now, what does that mean, though? Risk of harm to yourself? Does that just mean that I'm talking about suicidal thoughts, right. Because it is very much on a spectrum. And so I kind of light heartedly tell them, look, if you, you know, because I try to normalize it, and that's why I do it a little light heartedly and maybe throw in a little joke in that, you know, look, if you're, you know, it's, it's normal, you know, if you're struggling with mental health, it is normal to have some of those dark thoughts, right.

And just because you have them, I want you to feel safe telling me, because if you do, you know, and if you do, I'm not going to hit the button on my desk and the two big guys are going to come. Right. And I think it makes people feel a little more comfortable, you know, knowing that I'm not going to do that, that this is something, this is a safe place that we could talk about it. However. Right. When that happens, as a therapist, I need to do a risk assessment. Right. And that's looking at, do I have a plan?

Do I have the means? Do I have the ability to do that? How serious is that plan? You know, and if it's serious enough, then, you know, that's something that we have to have a conversation about of what is the next step? What is my obligation at this time? So, yeah, so when we have that conversation, right. One of the things that I'll ask is on a scale, this is kind of my thing. On a scale of one to ten, how likely is it that you're going to do this, giving you an honest answer. And they'd be like, look, it's not likely a one.

Whenever this happens, we make a safety plan, and that consists of quite a few things, like, if I'm feeling thoughts, who am I going to call? Who can I reach out to? What coping skills will I use? And in worst case situations, I tell clients that you can call me. I want you to do all these skills first, but if it comes down to it, you can call me. Right. And programs like DBT have those rules where I first heard were part of DBT, dialectical behavior therapy for folks often with borderline personality disorder, other emotional regulation issues where it's all centered around primarily self harm, you know, and suicidal ideation.

Right. That therapists will actually give the clients, you know, a number that they could call however they want them to try to do every skill first. So, you know, that is one thing to consider. You know, those are some of the things that we look for as a therapist on whether we have to do that. And the last thing I want is to spring this on you now. I don't want this to be a surprise. And one of the other things to think about as well is when I work with teens, because there's a whole nother level and there are more risks to safety for teens and what I need to tell their parents.

So not just like emergency services. And I've had this happen so many times with teens, and I can't stress enough that we hate. I hate doing this. I hate having to make a child protection report. There's nothing I want. And I have to let teens know, here are the limits. Because when I break confidentiality, that can harm the therapeutic relationship, and they're less likely to tell me something. And sometimes a teen or someone will allude to it, and I'll be like, look, like this is something we need to talk about.

Safety is an issue. And yeah, maybe I'll need to, will need to escalate this. But I think even though, like, a client may be mad at you, I think at some point they respect that and it could help in the relationship because they trust that you have their best interest in mind, that you care. So it's uncomfortable for therapists, but it's something that we need to do. And I agree with to a certain level, maybe sometimes it's taken too far or that we have to report on situations that maybe we shouldn't have to because it's like, where's the line?

And it's not always a wide line where it's obvious that I have to report this or not. Sometimes it very much is. Another one that I talk about, too, is abuse to a child in any way. Like if a client reports they abused a child in any way, automatically have to do that. And elderly abuse, too. I've had to make reports for that. And, you know, the question sometimes is how many degrees of separation? Because if I hear about that and even if it's not in a work situation and I directly hear about that, in some instances, I do have to report that, even though I'm not somebody's client.

So that's another. So there's a lot of, like, ethical issues here that are tricky. And I think, again, if I am going to, you know, distill this down to one takeaway, it's that it's really important for you to know if you're going into therapy, what you're, I mean, what you're getting into. Right. I mean, maybe that's not the best way of phrasing it, but, you know, knowing what is within the bounds, within the confines of what is ethical for a therapist and their requirements and what you are able to communicate to them and having clients be comfortable and destigmatizing self harm and suicidal ideation so that we could talk about it more, talk about it more openly and be able to help and not have clients again, because that's the dichotomy is do I, you know, if I know my therapist can report me, well, now I'm less likely to tell them when I may actually need to tell them.

So it's a really, it's a really delicate push and pull, and there's not always a great answer for it. But, you know, I encourage people because of what that person in the email had told me about what their follower or whoever that was involved in their group said that, like, I'm afraid to reach out because I don't want to have to go to the hospital. And sometimes that's what needs to happen, and worse things can happen. And sometimes that can be helpful to be in that safe place for a few days, getting the meds adjusted or just clearing your head, because sometimes you have these, you know, these urges, and they do often go away, but if they keep happening right, then that risk goes up.

So, anyway, a little bit of a heavier topic, but I think that, you know, maybe some of you are thinking about going to therapy. Maybe that's a hesitation for you. But I think also, you know, for those of you who are interested in mental health, and how the system works. I mean, I think it does bring up some interesting philosophical and ethical questions that are worth talking about and that you may all find interesting in some way. So anyway, if you have any more questions, feel free to reach out.

I appreciate you joining this live stream, and until next time, stay safe, and we'll see you later.