The case I describe here presents two ethical dilemmas: (1) how to respond when confronted with a presumptively dangerous client (based solely on self-report) evaluated for an agency (limits on disclosure of confidential information in Section 4.05 of Privacy & Confidentiality in APA’s Code of Conduct) and (2) how to present the case in present context while being faithful to certain details of the case and adhering to the Section 4.07 of the Privacy & Confidentiality Section.

I was a clinical director at an outpatient mental health agency in a moderate-sized New England city. One day the receptionist at the front desk informed me that a young man had been referred to the agency by an HMO for treatment of depression. All of the intake therapists were occupied, so I instructed the operator at the front desk to send him to my office. A 25-year-old Caucasian man came in and took a seat. He appeared, at first glance, well dressed and well nourished. He was remarkably articulate, but his affect was flat (and remained flat throughout the interview). At no point was there any evidence of thought disorder, delusions, or paranoid ideation. He reported no history of major mental illness. Although his current presenting problem was depression, it became evident over the course of the interview that his depression was long-standing and severe, with bouts of suicidal ideation (and several attempts).