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Dr. Saltzman:

I am a 25 year old male. I have been to psychologists, neuropsychiatrists, etc. a number of times since a pseudo-suicide attempt from when I was 20 (the purpose of the overdose was to force myself into some sort of treatment for other issues). I find myself unable to open up and be honest with mental health providers or doctors.

This particular medium of discussion does provide me with the opportunity to ask a question that has held me back.

On all outward appearances, I have a good life. Respectable job, stable, and self sufficient. My larger concern, however, is some of the thoughts that go through my head. Often, my thoughts seem to be outside of my control and beyond what any "sane" person would think about. I know that they are not normal, but fear being committed if I divulge them to a psychologist. There in lies my question. What are the rules... I know/feel that I need some form of treatment, but I think that if I tell anyone some of the things that flow through my head I could be committed or heavily medicated.

Could you elaborate on the legal responsibilities of a psychologist and the concept of confidentiality?

Norm D. Pleum

Dear Norm D. Pleum--

As you may know, my office is in Todos Santos, Mexico, not in the United States. Since I do not practice in the U.S., my knowledge on the matters you raise may not be totally up to date. That said, as far as I know, a licensed psychologist in most U.S. states has a positive responsibility to report to the authorities any communication of a patient which the psychologist believes might indicate that a third person is in imminent and serious physical danger from the patient. For example, if you tell me that you feel like killing someone, and have been planning it, and if I begin to believe that you mean it seriously, and intend to carry out the killing, then I must report that to the police. Other than that special case, there should be total and complete confidentiality of anything you tell your doctor unless you specifically authorize the doctor to share it with a third person.

As a patient, you have the right to inquire of your doctor what standards he or she uses in regards to patient confidentiality. If necessary for your peace of mind, you might ask the doctor to put this in writing in order to avoid any misunderstandings. And you can do this in the first interview so that you will not have to reveal your problematic thinking until you have the assurances you require.

The symptoms of disturbed thinking that you report indicate that you probably need treatment, and since you already know that anyway, I suggest that you seek professional help immediately. Without treatment, the kind of symptoms you mention almost invariably worsen, so please don't delay.

Occasionally a patient might have to enter a treatment facility against his or her will, but this is rather uncommon. In my experience, involuntary commitment happens only when the patient is frankly psychotic, and dangerous, in other words, when a patient is so far out of touch with consensual reality that he or she presents a real physical danger to oneself or to others. It seems clear from your letter, as well as your sense of humor, Norm D. Pleum, that this is not your state of mind, so I imagine it unlikely that involuntary commitment would happen to you. Most likely, you will end up receiving the care and help you need on a totally voluntary basis, and will be glad you are receiving it.

Be well.

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