A Sixteen-Year-Old, Thirty Tablets, and a Promise
Leah, 16, is referred by her school counsellor to community mental health. For six weeks she has cut her forearms, and today she tells you she has hidden 30 of her mother's amitriptyline 25 mg tablets and plans to swallow them on Saturday night once her parents are asleep. She drinks with friends most weekends. She is calm and articulate, and says that if someone found the tablets she 'wouldn't try very hard to stop them.' She insists you tell no one: 'Mum will fall apart and Dad will say I'm doing it for attention.' Her parents are separated and she lives with her mother, who has treated depression. Before she says anything else she asks you to promise confidentiality. No psychiatrist is available until Monday; it is Thursday afternoon.
1. How do you handle the confidentiality request, and what is your ethical and legal position?
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I do not make a promise I cannot keep - and I say that at the start, not after the disclosure.
- Framing: 'What you tell me is private between us, and there are limits I have to be honest about. If I think you are at serious risk of being harmed or of harming someone, I have to act on it, and I will tell you what I'm doing and why before I do it.' That is honest, and it means the disclosure that follows is not obtained by deception.
- The limits here are not discretionary. A specific, lethal, imminently planned act in a minor is exactly the situation in which confidentiality gives way. In most jurisdictions parents or guardians must be involved in the care of a 16-year-old, and the duty to protect overrides the request.
- Capacity is decision-specific and developmental, not binary. Her calm, articulate presentation is not evidence she can weigh a TCA overdose. Her stated ambivalence ('wouldn't try very hard to stop them') argues against settled intent, which matters for formulation - but it increases, not decreases, my concern.
- What I don't do: I don't get her to promise not to tell, I don't negotiate a 'secret safety plan' with a child, and I don't tell her that if she refuses I'll do nothing.
Documented: the request for confidentiality, my explanation of its limits, her response, and the rationale for what followed.
2. What is your risk formulation, and what is your immediate safety plan given that no psychiatrist is available until Monday?
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Formulation - high risk, driven by means and lethality more than by stated intent.
- Risk factors: six weeks of self-harm; a specific method, dose and time; accessible lethal means in the home; alcohol use, which disinhibits and is often present on a Saturday night with friends; hopelessness and the belief that her parents will read her as manipulative; maternal depression, which reduces the availability of a protective adult; ambivalence about being stopped.
- Protective factors: she sought help and told someone; she is engaged and articulate; school involvement.
Why TCA overdose matters specifically: amitriptyline is lethal in overdose, causes arrhythmia, and there is no antidote you can give at home. The 30-tablet access is the most modifiable factor in this whole picture.
Immediate plan:
- Same-day contact with her mother about safe storage and disposal - this is the single highest-yield intervention and it must happen today, not at the Monday appointment.
- Same-day face-to-face medical and psychiatric review; if it cannot be arranged, urgent care/ED assessment today.
- A written safety plan with her: warning signs, coping steps, people to call, crisis numbers, and what to do with the tablets.
- Explicit instruction that a 'no-suicide contract' is not a plan and not a substitute for means restriction.
- Follow-up contact within 24–48 hours - with a person, not a letter.
Documented: formulation, the plan, who was told, and her response.
3. How do you involve her parents without destroying the alliance - and what if she refuses?
Read the worked answer
Involve her in the telling, and be clear that the telling is going to happen.
- Tell her first, in advance, not as a fait accompli. 'I'm going to speak to your mum today. Do you want to be in the room when I do, or do you want me to do it first and you come in after?' Giving her the choice of how, while being unambiguous about whether, preserves respect without handing her a veto over her own safety.
- Keep it to the minimum necessary. The purpose of the conversation is the tablets, the plan and the safety plan - not her drinking, not her self-harm history, not her confidential disclosures about her father, unless those bear directly on risk.
- Anticipate both reactions. Her mother may be frightened and angry; her fear will look like blame and Leah will read it as confirmation that she is a burden. I would prepare the mother beforehand on what to say and what not to say, and frame Leah as a young person who told an adult - which is the thing we want her to keep doing.
- Address the mother's access to lethal means directly, in a practical, non-accusatory way: locked box, or return to pharmacy.
- If she refuses: I tell her once, plainly, that I am going to do it anyway, that this is what caring for her looks like, and that she can be angry with me. Refusal does not change the action. I would not, however, let the disclosure become punishment - I offer to be present, and I keep the relationship open afterwards.
Documented: what was shared, with whom, why, and Leah's views.