A 20-yr old homosexual male who is active in gay rights and political
issues has come in for therapy.  He is guarded and suspicious and
after three sessions still has not shared any deep feelings.  He
states that it is getting harder for him to escape the prejuudice and
stigmatization of being gay.  It appears that his homosexuality is not
an intrapsychic conflict.

What is your Dx and Tx Plan?

Later he tells you that he has been thrown out of his church and his
parents rejected him and he doesn't want to talk about it.

What is your next step?

He tells you that he is going to blow up the church; what is your
protocol?

what would you include on an intake?

Under some countries' laws, psychologists are required to breach
confidentiality if they have reason to believe that a client may be at
risk of harming themselves and others.

Were I counselling this client, I'd make a serious assessment of
whether or not he had the means an intention to carry out his threat
of blowing up the church. If I was convinced a) he was serious, and b)
he had the means, I'd break his confidentiality to stop it.

(I have an undergraduate degree in psychology, however I am not a
counselling psychologist).

Hi Carmen,

I'm a mental health professional and I am intrigued by your
hypothetical scenario. I think the best answer to the protocol portion
of your question depends on the setting in which you are practicing.
For example, if you are a private practitioner who is alone in an
office your protocol would differ from a clinician in a setting with
multidisciplinary colleagues (such as a security staff, a
psychiatrist, crisis counselors, etc.) Protocol would further depend
on whether or not you have the authority to involuntarily detain your
client for further psychiatric evaluation and/or treatment if
necessary. And, as Susannah indicated in her comment, your state and
local laws also have a bearing on your protocol.

Susannah is correct in suggesting that you assess your client's intent
and access to the means necessary to carry out his threat. But you
should also assess his history (hopefully you did that in your intake
interview in your first session.) Does this client have a history of
violent behavior toward others? Toward animals? A history of trouble
with the law? Any pending legal actions? Is he abusing alcohol,
prescriptions, or illicit substances which could impair his judgment
and inhibit impulse control? Does his threat to blow up the church fit
his general demeanor and presentation from earlier visits? Does he
have a personal or familial history of mental illness?

Your intake interview could also vary based on your client's mechanism
of referral. Is he a voluntary referral who seeks therapy of his own
accord? Or is he court-ordered? Is he an EAP mandated referral from
his employer? All these factors can influence what you ask in the
initial intake interview.

As a final comment, is it not perhaps premature to say that your
client is not conflicted regarding his sexual orientation if he hasn't
yet disclosed "deep feelings" and is reluctant to self-disclose on
other matters? This is probably only a small point given that the
major concern is his potential to harm others, but still a point worth
mentioning.

Best wishes,
fsw

Good analysis susannah.  What would be your diagnosis and treatment plan?