Being a psychotherapist is a complicated job. Not only must you be knowledgeable about human behavior, psychodynamics and various techniques of doing therapy, but you have to be prepared for unexpected dilemmas . Two cases are presented below which bring up potential legal and ethical issues as well as technical considerations, which the therapist has to take into account to best help the patient.

These vignettes are based on real cases which I have  either been involved with as the therapist or as  the supervisor or I have read about them or have been told about them by a colleague. Some details may have been changed to protect confidentiality.

All the cases are at least 10 years old. Readers of this blog are welcome to express their opinion about the cases. We all recognize that in a real clinical situations, there would be much more information available about the patient which might help in making a decision.

In a future blog, I will present further discussion about these two cases.

Case #1

The   patient is a  26 year old young women who came into therapy because  she was depressed about her inability to complete things. She had started college twice and dropped out and as a adolescent she came home from sleep away camp twice. Her goal was to go to nursing school some day in the future. She had many friends but had trouble keeping a boyfriend, She was attractive but was somewhat inhibited and only on occasion would allow herself to have sexual relations which she would enjoy. Her parents  were divorced when she was 6 years old. Her father is a physician would visit her periodically as a child  and when she  was older she would visit him and  his new wife . She always felt close to them and their two children. Her own mother was an alcoholic and when she was younger her behavior was quite erratic. At time she was physically abused by being slapped around. Other times she would have to take care of mother by making food for her and sometimes would even stay home from school . Despite poor attendance she got good grades. She herself does not drink or take drugs.  She shows no evidence of a major depression or psychotic symptoms. She is often moody but doesn’t appear to have hypomania. She becomes angry when she is disappointed. As a preadolescent she saw several therapists and  she had 2 or 3 brief trials of therapy in the past 3 years  including several weeks of a trial on an SSRI which she didn’t feel made any difference. She is currently in treatment with psychodynamically  oriented psychiatrist who has decided not use medication at present.  She has been coming for 4 months 2x/week ( Tuesday and Friday).   She says this is the first time she is making progress in therapy as she feels she can talk freely and is not being judged.

During her last session on a Friday very close to the end of session, she said , Whatever we say here is completely confidential, isn’t it?” The therapist replied, “Why do you ask this question ?”  The patient then went on , “ You know that baby sitting job that I have been doing every Saturday nite for Mr. and Mrs. Woodman my neighbor’s   15 month child.?” Well last week the kid was a real problem. He was whinning all the time and wouldn’t listen to me. The final straw was that he spit on me. I lost it  and slapped him    real hard across the face. His face got really red and swollen. I put some ice on it. I will never do that again.” The therapist, was stunned and before she could say anything, the patient said , “Well, I know my time is up” and got up and left.

Should the therapist do anything with this information. Is the therapist required to notify anybody? What are the  legal  and therapeutic implications ?

Case #2

A senior therapist  is supervising the following case. The patient is a single 36 year old dental hygienist living in Manhattan who is in her second year of three times / week psychoanalysis. She entered treatment because of difficulty trusting men which has been related to an inconsistent and insensitive father who shared with the patient the fact that he was cheating on her mother. The therapy has been going well and the patient has made progress in her ability to accept interpretations, have her own insight and utilize insight through her understanding of the transference.

The patient came into a recent session a little anxious and perplexed. She related the following incident . The other day after coming home from work she  rode up in the elevator with a young man a few years younger than her  who lives across the hall from her with whom she has a causal acquaintance. She believes he has a minor position in the union and always viewed him as trying to act like a wannabe tough guy but “a nice kid.”  He was pacing back and forth and seemed scared and she asked if everything was Ok. He asked her if she had a beer or a drink. She invited him and gave him a beer. She distinctively heard him say half to himself, “ I can’t believe I helped put someone to sleep.” When she asked him what did he say, he said it was nothing. They chatted about incidental things and he thanked her for her time and left. She wondered if that were something serious like someone being killed but then became scared and changed the subject and got into talking about her family, dreams and other things that were all continuation of issues she had been recently talking about. The therapist didn’t see any direct or indirect references to this subject in the next two sessions leading up to the  supervisory session.

Does the supervisor t have any obligation to either to suggest  or urge his supervisee  to try to influence the patient to report this information to the authorities and  is the therapist or the supervisor  obligated to do so.? What are clinical and therapeutic implications for the therapist  to spontaneously bring up this incident if the patient is not talking about it ?