Working With Threatening And Dangerous Clients
Nothing strikes fear into the heart of counselor faster than hearing our counselee threaten to harm herself or someone else, or even worse, disclose that they have already have. How do we respond? What should we do? Or not do? Even if you are a church based counselor, it is critical that we are familiar with the ethical and legal dilemmas involved in such cases.
Briefly, here are four areas we must be vigilant so we will handle these difficult situations in a clinically sound and ethically responsible manner.
Know your Level of Competence
Recently I was asked by a pastor to counsel a man in his church whose grandson had disclosed, sexually abused him. This potential client posed a danger to other children. Was I trained to assess this risk? Did I have the skills to work with this person?
Being a Christian, obtaining a certificate, or having a license to counsel doesn’t guarantee you have the level of training or expertise necessary to counsel certain individuals with particular problems. I would not want my family doctor to do open heart surgery on me.
The apostle Paul writes “Love does no harm to its neighbor” (Romans 13:10). When we agree to work with people who have difficulties beyond our level of training or expertise, we risk hurting them and possibly others that they interact with. Make sure you have a good network of competent Christian counselors if you need to refer to someone more qualified than you.
Know the limits of Confidentiality
Most counslees assume that everything they tell us is confidential. That is not true. Counselors must provide new clients with information in writing regarding the counseling process and the limits of confidentiality so that they are informed, prior to telling their story of the consequences of certain kinds of revelations.
A while back, even after reading my confidentiality guidelines presented ahead of time, a new client asked me if everything he told me was confidential. I told him most of what he told me would be held in the strictest confidence, but if he told me he was going to hurt himself or hurt someone else or had abused a child, then I would break confidentiality. He said it was one of those three and then disclosed that he molested a child. I was thankful that he was fully aware of the limits of confidentiality before he confessed to me.
As a counselor, you must make yourself aware of the laws in your state regulating your professional responsibilities and what you must report. Every state, has mandated reporting laws regarding the disclosure of child abuse, but the criteria of what constitutes reportable abuse might vary from state to state.
In addition to things we must report like suspected child abuse, or dependent elder abuse, there are things we may report, thereby breaking confidentiality. For example, if a client threatens to harm herself and other strategies like a suicide contract, increased monitoring, or extra sessions haven’t helped to lessen her suicidal intent, we may choose to inform her family, or when necessary call the police to initiate an involuntary commitment to prevent her from harming herself.
When a client threatens to harm an identified person and in our judgment, that threat is credible, notifying the proper authorities may not be sufficient. In certain legal cases a counselor has been held liable for not warning the intended victim. Subsequent cases have also suggested that we have a duty to warn not only the victim but others that may be in close proximity to the intended victim (such as a child or roommate). Since it is impossible to predict with 100% accuracy dangerousness ahead of time, violation of a client’s confidentiality must be undertaken with great care and consultation with others.
Know how to assess danger
The art of counseling involves learning to discern what a client is really saying. When someone says, “I wish I (or someone else) was dead” are they talking suicide or homicide or just expressing frustration with their current stress levels or relationship difficulties? How do we distinguish between the client who vents in scary ways and those who may carry out their threatening words?
The best predictor of future violence is a history or pattern of past violence. Make sure you take a careful history of previous threats and violent behavior and whether there is a family history of these behaviors. In addition to good history taking, talk with family members (when permission is given) about their perspective and whether the client has threatened them or acted out in violent ways. This is especially important when working with domestic violence as perpetrators typically minimize their behaviors. Don’t forget to contact previous counselors or pastors the client may have seen or obtain records from prior hospitalizations. These records give you a more informed picture and enhance your ability to provide competent care.
Consult with other professionals such as a psychiatrist, medical doctor, an attorney, or a person who specializes in ethical dilemmas if you unsure whether to report, who to inform or how to proceed with treatment.
Know how to keep good records
Good documentation is essential in every case, but with dangerous and threatening clients, it’s critical. Make sure you have a treatment plan and you update and date it regularly. In your case notes record what specifically a client said, your assessment of the threat, what you did and why you decided to do it. In addition, make sure you document and date who else you informed, what phone calls you made, who you consulted and the results of these contacts. Make sure your records include a signed informed consent for treatment and the limits of confidentiality.
Unfortunately, if someone later challenges your care or treatment, it is their word against your records. If it’s not down on paper, it’s as if you didn’t do it.
Working with threatening and dangerous counselees can be scary and presents many difficult clinical, legal, and ethical dilemmas. It is imperitive that we understand and act in a responsible way as we weigh the risks involved to our clients if we break confidentiality with the danger to potential victims and to ourselves.
Posted on October 10, 2012