All Therapists are Gamblers

I've never been to a casino, or bought a lottery ticket, but I still gamble. When I work with high-risk clients, I take a gamble every time they walk out the door. I like to think it's not much of a risk, because I'm experienced enough to sense a client's degree of risk/safety - but we all know we can be wrong, and situations can change rapidly.

Because we (as a profession and wider society) value self-determination and are loathe to infringe on anyone's free choice, the threshold is quite high for holding someone against their will on psychiatric grounds. Unless someone is immediately suicidal or homicidal (like, they have a plan and intend to enact it if we let them walk out the door), or behaving so bizarrely that they are at imminent risk of physical harm (wandering down the middle of the street; refusing all food and drink - things like that), they don't have to go to the hospital...and we, by extension, do have to let them walk out the door.

For most clients, most of the time, that's not much of a gamble. But there is a definite gray area where you know the client is at risk, but not enough so to override their self-determination. Sometimes, these clients can be persuaded to be hospitalized voluntarily - but often they refuse.

I find myself with several clients who are hanging out in the gray area, making me a little nervous as they walk out my door.

I have a psychotic client who has reportedly spent most of the week hiding out in her closet, eating only sporadically, and once going to the bathroom in a bucket..."but I only did that one time, Natalie!" She absolutely refused all efforts to convince her to go to the hospital, assuring me her family would be checking on her regularly, and promising to go to the hospital if they found her hiding in the closet again.

I have another psychotic client who missed his last appointment with me (though thankfully he did go to his med evaluation). He has to leave stores and other social settings sometimes because the voices tell him to hurt people.

Another client also keeps to herself because she has impulses to hurt people. She is able to choose not to act on these impulses by thinking about the consequences for herself and her children. But she hopes to someday main or kill the people who sexually assaulted her in the past (including a brother) and does not plan to continue with therapy to work on any of these issues.

Today I saw a woman who has habitual suicidal ideation which she does not intend to act on - but it has gotten markedly worse this week, after a loss and a break-up, and she decided on a method long-side (OD on IV heroin). Even though she assures me she has not intention of acting, I am not terribly comforted by that. She did agree to go to a partial hospital program...but can't start until Tuesday.

Finally, I have a client with OCD who has intrusive, obsessional violent thoughts toward himself and others. These include sexual aggression against children, homicidal ideation, urges to self-injure (because he considers the thoughts of violence toward others signs of his own badness), and thoughts/plans about harming his mother's cats. My worry is assuaged by the fact that he has never tried to harm any other people...but he has engaged in non-suicidal self-injury, and attacked (but not tried to kill) a cat.

So, with all of these clients, I let them walk out the door with some definite trepidation. I'm mostly sure they won't come to harm before I see them next...mostly. I'm wondering how other people would navigate these kinds of risks. How do you manage safety issues on an outpatient basis, and when do you decide that the risk is too high? When and how do you seek consultation on risk issues? In short, what's your gambling strategy?