Confidentiality and the unique nature of the psychotherapeutic relationship

Psychotherapists are treating more or less like any kind of health professional when it comes to confidentiality. Just like your doctor is not supposed to go talking to her friends about your health problems, a psychotherapist is not supposed to go talking about your mental health. What this means practically is something that you (hopefully) already know:

psychotherapy is confidential, meaning nearly everything that is said in my office is kept secret.

There are a few exceptions:

  • If someone tells me that he/she is going to kill himself or another person, I have to take action to stop it. Usually this means calling the police or local psych emergency services.
  • If someone tells me about a case of child (or elder) abuse, I also have to report that to the state department of child protection and/or the police.
  • If I'm subpoenaed by a court or being investigated by an oversight agency, this might result in some confidential information being shared (depending on the nature of the investigation/case)
  • If you give me written permission to talk to specific people or organizations.

This last case is the cause for the vast majority of my disclosures of information as a therapist. For instance, I need to give certain information (billing codes, sometimes summaries of treatment or my notes) to insurance companies in order for them to pay for therapy on your behalf. If you come to see me and use insurance to pay for therapy, you sign a form that gives me permission to give this information.

When it's to your benefit, I may also get your written permission collaborate with your other health care providers. The idea that it's for your benefit is important: even if you give someone permission to share your protected health information, the idea is that it's not gossip or for their amusement. Sometimes the ethics of information sharing for the client's benefit is straightforward--say I call a psychiatrist because some medicine she put our mutual client on doesn't seem to help. Pretty straightforward. But it's not always so clear. While your primary care doctor and your cardiologist might have no qualms about sharing information, therapists often do have qualms, especially with providers who aren't mental health professionals.

The question is like this: how much does your cardiologist really need to know about your mental health, even if it's impacting your heart? Another way of looking at it is like this: Client-therapist relationships are typically highly privileged, meaning there's stuff you'd tell a therapist you wouldn't tell your PCP or your podiatrist. If your therapist turns around and tells them, it could feel quite violating. So even though professionals are given a lot of leeway about talking to other healthcare professionals, and even though you probably signed a piece of paperwork at your first doctor's visit that gives them permission to talk to anybody they need to in order to facilitate your care, a typical therapist will get formal and explicit written permission to talk to another of your health care providers. This protects the exceptional nature of the therapeutic relationship, makes sure you know about and are okay with any disclosures of information, and protects the psychotherapist legally.

Likewise, if you give written permission--typically if you complete and sign a form usually entitled "permission to release protected health information," a therapist  can talk to someone else--maybe a family member or a friend--about what's happening.  Usually I make sure I know exactly what information is okay to give and not give. Again: client-therapist relationships are usually unique and should be protected.

Another important note or two: If the client is under 18, parents also can get information about treatment of their child. I don't usually see clients under 16 or so, but if I'm working with an adolescent I make sure to talk to the parents specifically about what information they will want so that the rules are clear. Just like anyone, a 17 year old is not going to feel very comfortable talking about certain things (for instance, her mother) if she knows that her mother is going to get the scoop from the therapist.

These rules have some other broad implications:

Even the identity of my clients is protected. So if someone calls me and wants to know if her brother has been seeing me for therapy, I have to say that I'm not allowed to tell the caller.

Likewise, if two of my clients know one another, I can't tell either of them that I'm seeing the other. That said: I can and will ethically refuse to see a new client if I'm seeing someone close to him/her and it would get weird, but I have to give a vague reason (like "I can't see you for ethical reasons" or "I can't give more information, but I think we know people in common and it would get weird.")
After the recent election, someone asked me if Mitch McConnell is one of my clients. Why he asked this, I have no idea, especially since Senator McConnell is from Kentucky and works in Washington DC, while I live and work in Massachusetts but--as you might guess, I had to ethically respond, "I can neither confirm nor deny the identities of any of my clients."

In the normal course of things, it also means that if I bump into a client at the grocery store or in downtown Northampton (or any public setting), I can't reveal in any way that I see him or her for therapy unless given some kind of permission to do so. Usually this means (for simplicity) that I don't acknowledge the person at all unless the person acknowledges me first. In short, I follow their lead: if a client waves and says hi, I assume that it's okay if I do the same. If someone introduces me to her friend, I assume it's okay for me to acknowledge whatever she's said.

Again, this is about the nature of the client-therapist relationship. A lot of stuff can happen in my office. It's comforting for most people to know that, even though I'm a person who leaves my office and buys groceries or parks in the lot behind Thornes Market, what they talk about (and even that they were in my office in the first place) doesn't get shared unless they're okay with it.
Sometimes when I explain this to new clients, they'll say, "well, it's fine with me if you come up to me in public." This may be true, but it's hard to tell: I explain that they might feel different if they were around specific people--a new romantic interest or people from work. Or, after we get into the midst of therapy, they might feel differently no matter who they're around. I always point out that if they want to acknowledge me and talk to me in the moment, they can also do that, but I'm not going to make any assumptions.

I should also note: clients can do whatever they want in terms of confidentiality. The rules and guidelines govern me, not them. I will, as noted above, follow their lead. I have certainly had clients who happily come up to me in public and want to talk, or even tell the people they're with (or the people that I'm with) that I'm their therapist and how great I am. And, my own modesty aside, that's also fine.

Other therapists will have other rules and different ways of handling situations, but we all follow generally these same guidelines.  Actually, (nearly) every healthcare provider follows these guidelines. But psychotherapists, by in large, take these guidelines very seriously because of the nature of our work. Sometimes this is criticized, especially as managed care moves psychotherapists into doing more cognitive and short term work. This presumes that because healthcare is becoming faster paced and less thorough, that therapy should too. Even if therapy as a whole moves in this direction, it presumes that the unique nature of the client-therapist relationship can be cast aside. Granted, everything in this world needs to be able to change and adapt, including the institutions of psychotherapy. But psychotherapists aren't primary care doctors. It is a different science and art. And I think people will always think of us as such, and relate to us differently. So I think its uniqueness should be respected, and do my best to do so.