I had a client who came into my office who was stating that she felt suicidal because she’d had a sexual relationship with her former therapist. The evaluation and management of a suicidal client is frightening to say the least. As I approached the suicide assessment, I kept in mind three things: 1) I need to consult with a colleague for another opinion. 2) I make sure I document, document, document everything. 3) I evaluate the client’s risk for actually killing herself. The risk factors for suicide are:
1. A client with a mental diagnosis, especially depression and substance abuse, or Borderline Personality Disorder that increases risk.
2. People over 45 years old are higher risk.
3. Gender – men will use more lethal means such as a gun, women will try more often such as using pills.
4. People who have never married, who are divorced, widowed, recently separated are highest risk.
5. Recent loss of a loved one increases risk.
6. Have there been any previous suicide attempts?
7. Has there been a recent job loss?
8. Is there a history of suicide in the family?
9. Does the client have a history of violent outbursts or impulsive behavior?
10.Does the client have a specific plan?
This was the time that I had her sign a no-suicide contract. In the contract, she agreed to not hurt herself and that if she felt she couldn’t stop herself, she’d call 911, or another person who was close to her. She also agreed to return for help at her next appointment. I also asked her to talk with her family about her feelings. She did not need to tell them any specifics about what had caused her distress, but she told them that she was extremely depressed and is feeling suicidal.
I explained to her at length about dual relationships. I explained to her that usually when there is an ethical violation such as a therapist having a sexual relationship with a client, the relationship actually begins with a non-sexual relationship. The relationship begins in good faith and as time passes, the boundaries between the client and the therapist begin to deteriorate. I told her that the risk of harm occurring to the client increases as the therapist and client become more intimate and there is a greater power differential between the client and therapist just as there exists between men and women in general. Researchers have found that a subset of nonsexual dual relationships ‘accurately predicted’ the ‘erotic practitioners’ in more than three fourths of the cases. I talked to her about how predatory professionals will exploit and seduce female clients deliberately for their own satisfactions.
I proceeded to educate her about the Therapist-Patient Sex Syndrome. Some of the identified10 aspects of the syndrome may be experienced by the client, or all aspects may be experienced, such as ambivalence; a sense of guilt; feelings of emptiness and isolation; sexual confusion; impaired ability to trust; identity, boundary, and role confusion; emotional liability (frequently involving severe depression and acute anxiety); suppressed rage; increased suicidal risk; and cognitive dysfunction (especially in the areas of attention and concentration, frequently involving flashbacks, nightmares, intrusive thoughts, and unbidden images. My client was indeed experiencing almost all of the symptoms described. These symptoms are all symptoms of Post Traumatic Stress Syndrome.
I pulled out my copy of the American Counseling Associations ethical standards and read her,
“A.4.a. Avoiding Harm: Counselors act to avoid harming their clients.
A.5.a. Current Clients: Sexual or romantic counselor-client interactions or relationships with current clients, their romantic partners, or their family members are prohibited”
I told her that the former therapist needed to be reported to the state licensing board. I warned her that her confidentiality could be breached as a part of the reporting process. I also told her that she needed to engage a reputable attorney because there was a strong possibility that the former therapist might try to lie his way out of the accusation and blame her by saying she was making false claims.
She asked me what would happen to him and I told her that he could be the target of a lawsuit. He could have his license revoked or suspended as well as lose his insurance coverage and his job. In the State of California there is even criminal liability when a therapist initiates a sexual encounter with a client. My client finally understood that this ethical violation was the most egregious and damaging thing that a counselor could do to an unsuspecting client.