This paper examines the clinical and ethical challenges counselors face when clients disclose critical information at the very end of a session. Beginning with general guidance on how to handle last-minute disclosures professionally — including when mandatory reporting obligations are triggered — the paper then analyzes four distinct case studies: a depressed teenage boy (David), a grieving mother expressing rage (Melissa), a terminally ill patient (Eva), and a recently unemployed young man making a threatening remark (Shawn). Each case illustrates a different dimension of clinical judgment, from assessing suicidal intent to evaluating the credibility of criminal threats, and demonstrates why counselors must approach such disclosures on an individualized, case-by-case basis.
When a client ends a session by disclosing a critical piece of information — particularly when there is clearly no time to discuss the issue in full — it is incumbent upon the counselor to address the disclosure directly and briskly, with reference to the next session. To some degree, it might be possible to understand this pattern of disclosure as the client's way of setting the agenda for the next session, although in a number of cases it is quite obviously the client's way of stating something directly that they do not otherwise know how to disclose in therapy. It should not be treated as an invitation to extend the session past its deadline, as this would be unprofessional and would create the illusion for the client that sufficiently sensational disclosures will be "rewarded" with extra clinical attention.
Obviously, the counselor needs to take account of the content of the disclosure, because certain things — suicidal ideation, intention to commit a criminal act — legally obligate a counselor to report them to the appropriate medical or legal authorities. The first specific step would be to analyze what the client says in terms of whether it requires an immediate response or intervention with external authorities. This could mean calling a client's medical psychiatrist in the case of suicidal ideation, or calling the local police if a client appears to have expressed a genuine intention to follow through on a persistent revenge fantasy. It is necessary to approach any end-of-session disclosure on an ad hoc basis, grounded in the counselor's larger sense of the patient's mental state and stability.
The personal challenge, for this writer, would be evaluating patients who express hopelessness or potential suicidal ideation. My own instincts are so profoundly empathetic that the thought of a client taking his or her own life is something I can scarcely imagine, and my instincts would be to err on the side of taking such statements very seriously. Yet I am aware that many people in counseling feel safe to express their more despairing and bleak thoughts — disclosure that would be too vulnerable for them outside the therapeutic context — and that not every such statement requires medical intervention to prevent suicide. I believe the only way to meet this challenge is through practical experience: only after counseling a number of depressed persons, and being forced to evaluate their statements on an ad hoc basis, might I gain a better practical grasp of how seriously to take expressions of potential suicidal intent.
Case Study 1, "David," seems to be expressing potential suicidal intent at the end of his session. That is, at least, my instinctive reaction and worry as a counselor in response to his statement — "don't worry about me, I won't be a problem anymore" — delivered as he puts his hand on the door to leave, having just expressed thanks for my work as his counselor. David's age is one reason why suicidal ideation carries such elevated risk: at 15, he is undergoing tremendous physical and hormonal changes related to puberty, and brain development research shows that teenagers have less impulse control than older adults. At 15, David's brain itself is not fully mature, and will not be considered medically mature for a number of years.
In assessing David's condition, the fact that he appears "more withdrawn" during his final session suggests a definite worsening of his depression. It is worth noting, however, that he might also be feeling anxiety about being evaluated by a medical psychiatrist for medication. There remains a significant degree of social stigma attached to mental illness, and teenagers are no exception — even a 15-year-old client might feel some dread at the prospect of being placed on a pharmacological regimen.
I would stop David before he left and ask him to clarify his statement, simply because his depression does appear to be worsening, and he will be without medical supervision for a week while believing his relationship with me has formally ended. I would ask David directly whether he was thinking about suicide, and I would want his assurance that — despite the formal conclusion of our therapeutic relationship — he would please contact me if he experienced any suicidal ideation in the coming week. I would also contact David's psychiatrist with a full report of what I had witnessed, to alert him that the depression seemed to be deepening as David concluded his counseling. In this case, I think David might also benefit from a continuation of talk therapy in some form, given how dramatically his condition appears to be worsening at its conclusion, and I would make that recommendation to the psychiatrist as well.
"Grieving mother makes ambiguous threat about the Pentagon"
"Terminally ill patient makes a final, ambiguous farewell"
"Unemployed young man makes a potentially criminal remark"
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