Managing Risk

It can feel daunting to open up to a stranger especially when there are issues around the safety of the client which may require the therapist to breach confidentiality. In this week’s blog I want to explore how risk is managed in therapy. As with almost any aspect of therapy, this will vary between individual therapists. I can only speak for myself in how I manage risk, although some features of what I will be explaining will be common to most therapists.

In the initial session, I ask the client whether they have had any thoughts of suicide or self-harm. If so, I would then ask further questions to ascertain the degree of risk that they represent to themselves. A great many people have suicidal thoughts at some point in their lives. This does not, of itself, mean that emergency procedures need to be carried out. However, if they state that they have an immediate intention to self-harm then I would feel an ethical duty to take that seriously. If they felt unwilling or unable to contact their GP or get themselves to their local Accident & Emergency Department, then I would seek their permission for me to contact their GP on their behalf. If the individual declined that permission but were expressing serious intent to self-harm then I would inform them that I would be contacting their GP anyway. In any case, I would want to stay with the individual’s feelings of hurt, despair & anger so they may feel heard, understood, valued & connected. Sometimes, the experience of having someone stay engaged with them despite what feels to them as overwhelming, can of itself offer some sense that their feelings are containable, and through that, gain some sense that a future can be bearable. 

It is important that the individual feels heard. Subsequently, the risk questions can be raised & if necessary, ways of managing extreme risks can then be established.

If the individual is expressing anger towards others, then the limits of this need to be elicited. In the extreme situation of the client stating a clear intention to harm another, then there is an ethical duty on the part of the therapist to manage this risk to the other person. As a last resort this may involve breaching confidentiality to the police. This is very rare.

Also in the initial session, I check out with the individual their pattern of intake of alcohol & non-prescribed drugs, e.g. drugs used for recreation. Where there is heavy use, this may or may not suggest that the individual is using these substances as a means of managing difficult feelings. Given that therapy is often about helping clients find a way of healthily managing difficult feelings, the use of substances may prevent the client from facing the full intensity of their experience. Thus, it is important for the client to be aware that they need to be free from the effects of these substances (sober) when attending the sessions. Any client attending a session under the influence of a non-prescribed substance would be asked to leave & to return at a subsequently agreed date/time when they are sober. 

It would be a matter of some concern to me if the individual felt little motivation to address their heavy use of alcohol or drugs. Whilst I would normally encourage the client to be leading the direction of their therapy, in such circumstances, I would draw their focus back to their substance use wherever possible, trying to help them develop a compassionate understanding for such self-abusive behaviour. This is a delicate balance to maintain. On the one hand it would be easy to collude with their avoidance of the issue & on the other it would be easy to add to their sense of shame. By providing a non-judgemental relationship which keeps a caring focus on the issue being played out by the use of these substances, the individual may develop a stronger sense of self that is therefore more able to face issues without the need to “self-medicate”.


If you have any questions about this blog or any of the issues raised please feel free to contact me via my website: http://www.garycooktherapy.co.uk