What's Confidential and What's Not In a Client-Therapist Relationship?

People seek therapy to get a kind of advice they can’t get from anyone else. A person can ask a particularly insightful friend, spouse, or parent about life choices, employment woes, and so on, but the answers they get might not be the most effective. People with whom we have personal relationships may tell us what we want to hear or, alternately, they may be too critical of our choices. They may show less concern than is appropriate, or they may show too much. And when we speak casually about things with those close to us, there’s always a chance that information that was not meant for public consumption might be shared with others. This is not, of course, always malicious. How often have we been told a secret we then let slip because we didn’t know it was a secret? Such misunderstandings are a natural, if difficult part of social interaction.

Therapy, however, is not a social event. The client-therapist relationship rests on a specific kind of conversation with specific goals and parameters, and being able to speak freely about deeply personal matters, without fear of being taken out of context or having a comment impact a relationship, is part of its value. Which is why on top of a therapist to be objective and insightful, the promise of confidentiality is an expectation and in many cases a legal requirement.

Clients, though, cannot feel comfortable saying absolutely everything in a therapist’s office, and that’s something of which they have to be aware—for the benefit of all parties involved. While there are laws governing what a therapist cannot disclose, there are also laws governing what a therapist must disclose. The American Psychological Association (APA) has laid out some guidelines for when clients can expect confidentiality and when they can’t. So let’s delve into some of their observations, what they mean for the client-therapist relationship, and what the best solutions are for minimizing confidentiality confusion given the big problems, professional and legal, that can result from it.

What Therapists Can’t Share, And What They Must

There are some types of confidentiality that a client can reasonably expect from a relationship with a therapist. For instance a client would not expect a therapist to go to the bar after work and give a personally identifiable account of their divorce details discussed earlier that day, or to post it online, or to call the client’s friends and tell them about it. Such things could represent breaches of professional ethics and therapists making a habit out of it may face professional censure. Some disclosures of personal information may also violate the Health Insurance Information Portability and Accountability Act (HIIPA), a law that protects individuals’ personal medical information, including things regarding mental health.

On the other hand, there are particular topics that may seem confidential, and that are certainly personal, but that therapists are required to report to certain legal authorities. Clients and therapists must be aware of these. Not to discourage a client from speaking freely to a therapist, but merely to make it known up front that there are issues that, when discussed in certain ways, may unavoidably trigger discretionary or compulsory disclosure to legal authorities, without the consent of the client. Such topics that may fall under these rules are:

• Domestic violence when witnessed by a child, abuse, or child neglect;
       
• Intent to commit a violent act against another or attempt suicide;

There may be some exceptions based on the specifics of a situation and variations in state law.
If you’re a therapist, there are also issues of who you can tell about particular things after a therapy session, and what permission is required. For instance, if you want to discuss a young client’s trouble at school with the client’s parent, you might be able to without consulting the child, but you might need the child’s direct consent, depending on the laws of your state.

Confidentiality Confusion Creates Problems For Practices

An unexpected disclosure of information presumed confidential can potentially rattle an effective therapeutic relationship. Say, for instance, a client is speaking emotionally with hyperbole, and finds themselves saying something that literally implies an intent to commit violence. This can force a therapist to take action and alert authorities, even if the client later insists they were not a real threat.

As already touched on, state-by-state differences in disclosure laws can likewise cause confusion over what is fully private and what is not. If a therapist is unclear on the laws, they may inappropriately discuss a young child’s personal problems with a parent and unknowingly cross a line, inviting regulatory action.
Potential scenarios like this are why, for both clients and therapists, it is critical that everyone is aware from the beginning of therapy where the lines are.

With Onboarding There’s No Secret About Confidentiality

The best solution to making sure everyone understands the etiquette and the laws surrounding confidentiality in the therapist’s office is virtual onboarding. Using video-based onboarding resources specifically made for clients and patients, to walk each through what’s confidential and what’s not, keeps everyone on the same page.

Even the most detail-oriented mental health professional can use an occasional refresher on confidentiality, and if you have a group practice with many part-time and contract clinicians moving in and out, it means new faces joining up who might need a quick walkthrough before seeing clients. A video-based training solution easily available online will always beat a game of telephone about rules and regulations in a fast-paced, and nowadays often distributed, office environment.

Furthermore, the regulatory landscape can change quickly and, as already touched on, vary state-by-state. Having clinician onboarding resources that are regularly updated by people with regulatory expertise lets therapists know they’re not making important decisions about what they can discuss, and with whom, based on outdated assumptions.

Onboarding resources for clients, too, are critical in letting them know the red lines. Not to find ways around protecting the people these disclosure rules are meant to protect, but to make sure that clinicians can provide effective therapy even in delicate situations where these important laws may come into play.
An environment of mutual trust is critical to a productive client-therapist relationship, and understanding confidentiality from the outset is a part of that. Client and clinician onboarding are foundational to building and sustaining that trust on both sides.