Collect information in advance about your client, including identifying information, best contact methods, a home address or location, a personal contact in case of emergency, and contact information of local emergency personnel (e.g., law enforcement, child protective services).
Describe your strong preference to openly discuss suicide and to work collaboratively, even when clients are in suicidal crisis.
Make sure your clients know what specific behaviors will prompt an emergency response (e.g., if clients call or text and leave a message that they are suicidal, or if clients hang up or go offline after making a suicide threat).
Make sure you and your clients agree to an emergency plan (e.g., “I will contact the police and give them your address or your last known location”).
Confidentiality is limited when you are using video, online, or telephonic counseling modalities. In particular, you may not be able to ascertain whether your client is in a setting that affords privacy; other people may be present and able to hear or see counseling interactions. In addition, when using text-based platforms, you face the possibility of identity theft—you may not know whether you are really interacting with your client. One method of addressing these limitations to confidentiality is to establish a prearranged challenge question (Rummell & Joyce, 2010).
Directly discussing confidentiality strategies with your clients is recommended. Keep in mind that online and telephonic counseling can be equivalent to face-to-face counseling, but typically the factors that make online approaches effective include (a) establishing and maintaining a therapeutic relationship and (b) implementing evidence-based counseling strategies (Castro et al., 2020; Hanley & Reynolds, 2009). The Zur Institute has a complete comparative list of ethics guidelines pertaining to telehealth counseling across 14 disciplines/organizations, including ACA, the American Psychological Association, the National Association of Social Workers, and the National Board for Certified Counselors (see https://www.zurinstitute.com/ethics-of-telehealth/).
Boundary Setting and Tending
Professional boundaries are a part of all counseling. Appropriate boundaries help clarify the nature of your relationship and aid in establishing and maintaining therapeutic relationships. This is especially true when you are working with clients who may be suicidal. When regularly working with suicidality you might become more easily burned out, your judgment may become impaired, your buttons may get pushed, and in general you may feel increased vulnerability.
Clear boundary setting protects counselors and clients. Boundaries define the parameters of the professional relationship and model clarity, safety, and compassion. The hard truth for all mental health professionals is this: We cannot save people from pain or prevent them from making destructive choices. We can work with people to make changes in their lives—changes that reduce pain and increase joy, changes that may begin a positive momentum—but there are limits, and these limits should be carefully described and observed (see Case Vignettes 2.1 and 2.2).
The Lily and Brian scenario in Case Vignette 2.1 may seem extreme, but in our years of teaching, supervising, and working with difficult populations, we have seen similar (and worse) boundary extensions or breaks (R. Sommers-Flanagan et al., 1998). In telebehavioral health scenarios involving suicidality, you may get many requests to provide immediate assistance via text or telephone. If you respond to such requests with anything that can be construed as providing counseling, you have broken a boundary and begun counseling without establishing informed consent. Whenever clients are suicidal, the temptation to break professional boundaries can be powerful.
Specific circumstances or job demands may require you to give clients your cell phone number or email address, but beware of the implicit messages that accompany this boundary extension. You become responsible for whatever information is communicated through these channels. What are your boundaries for the number of calls a day, or the number of minutes for each call, or the number and length of emails or texts you are willing to read and respond to? Setting and maintaining nuanced boundaries can become slippery. We cannot tell you exactly which boundaries to set, because professional and community norms vary. Our best guidance is for you to consult, read your professional ethics codes, contemplate, and consult again. One more guideline: If you are reluctant to openly consult with colleagues about how you are handling boundaries with clients, then you should probably consult with your colleagues.
Case Vignette 2.1 Beyond the Boundaries
Years ago, a kind young volunteer named Lily was working at a homeless shelter. She became close to Brian, a man about her age who struggled with bipolar disorder. Lily was married and had a toddler at home. She spent many hours talking with Brian, trying to convince him to take his medications and get into a rehabilitation program that would train him for entry-level jobs. She was making headway. Brian became med compliant and went on his first job interview, but it did not go well.
After his disastrous interview, Brian called Lily. This was before cell phones. Even though her number was listed in a telephone book, Lily had written her number down for Brian, explicitly giving him permission to call. When she answered, Brian began sobbing, telling her that he was a hopeless case. He thanked her for all she had done, saying, “I just want you to know it’s not your fault.”
Lily was frightened. She insisted that Brian come to dinner at her house and spend the night on the family’s couch. She planned to call her volunteer director in the morning during his office hours. Ironically, calling the director after hours was a boundary Lily did not want to cross.
Brian came to Lily’s small apartment, ate dinner, and slept that night on the couch. He did not kill himself, but he did become a demanding force in Lily’s life that required several weeks of reboundary setting and extrication assistance from her volunteer director. Lily later went to graduate school in counseling and reflected on her choices with Brian. She was embarrassed by her well-intended but dangerous naiveté. She was grateful that nothing terrible had happened to her or her loved ones.
Pastoral counselors often have different professional boundaries than rehabilitation, career, school, or mental health counselors. Social workers may have different professional boundaries than psychiatrists or nurses. Licensure laws and ethics codes vary. Make sure the boundaries you set are consistent with the standards of practice in your community and within your professional discipline.
Case Vignette 2.2 Indirect Giving to Preserve Boundaries
Sharon was a school counselor who regularly visited with Hallie, a 14-year-old girl who lived in a group home because her mother was suffering from meth addiction. Hallie reported occasional suicidal thoughts. She was the brunt of jokes in the hallways because of her weight and wardrobe. Sharon was sympathetic and worried. She asked Hallie whether she could call the group home parents for a consultation. Hallie agreed.
The group home parents, Paul and Michelle, met with Sharon and Hallie. Together they made a plan for Hallie to see a mental health counselor and for Hallie to get an earlier ride home to avoid contact with bullies. Sharon also talked with the school principal about ways to address the bullying directly.
Because access to mental health counseling was limited, Sharon agreed to have Hallie meet with her for brief check-ins until Hallie got her own counselor. Sharon also connected Hallie and her group home parents to a school fund available for students to buy clothes, eyeglasses, and other items. Sharon did not mention that she was a