This article has been reviewed for accuracy by John Cottrell, Ph.D. in Clinical Psychology. Medical Disclaimer: The information and recommendations on our site do not constitute a medical consultation. See a certified medical professional for diagnosis.
Therapy is a safe place to disclose your innermost, darkest secrets, worries, and vulnerabilities, knowing that your therapist will not judge you and that what you say will not be revealed. In fact, that is the entire premise of the whole thing.
One of the pillars of a healthy professional relationship between a client and a therapist is confidentiality. Understanding that a client’s therapist will preserve their discretion by not disclosing the substance of therapy sessions facilitates sharing deeply personal ideas, feelings, and convictions. However, there are times when it is necessary to breach confidentiality.
Why do therapists break confidentiality? The circumstances under which a therapist must violate confidentiality are generally governed by state law, which means that they can differ from one state to the next. Depending on the state, a therapist may be required to break confidentiality for the following reasons:
- When clients present an immediate risk to themselves or others, violating confidentiality is required to remedy the threat.
- When the therapist detects mistreatment of a child, an elder, or a dependent adult.
- Once the client has requested that information regarding their case be shared with someone outside their therapist.
- When the therapist obtains a qualified court order.
This article will outline all you need to know about patient confidentiality requirements, when a therapist may be compelled to break client confidentiality and more.
What Is Patient/Client Confidentiality?
Patient/client confidentiality requires therapists, psychologists, psychiatrists, and most other mental health practitioners to preserve their clients’ privacy by not disclosing therapy details.
Confidentiality encompasses not just the substance of therapy but also, in many cases, the fact that a patient is in treatment. To safeguard client anonymity, therapists will often refuse to acknowledge their patients if they encounter them beyond the session. Other methods of maintaining confidentiality include:
- Not sending private patient/client information via voicemail or text.
- Refusing to notify third parties that a customer has an appointment.
- Not disclosing counseling details with a third person without the client’s specific authorization.
What Are Patient/Client Confidentiality Requirements?
Each independent counseling association has a standard of conduct that specifies expectations regarding confidentiality restrictions. Most associations recommend therapists retain patient anonymity unless they are mandated to disclose or feel strongly motivated to do so based on professional opinion. However, it is not as simple as simply adhering to your organization’s rules. Most states have legislation that either allows or compels mental health providers to share client information in specific circumstances. In addition, the Health Insurance Portability and Accountability Act (HIPAA) provides instructions from the federal government.
Confidentiality is a contentious issue because clients may withhold information if they fear their therapist will not maintain confidentiality. To maintain patient confidentiality, therapists should get acquainted with local legal requirements and the guidelines of their professional association.
Independent Counseling Association Confidentiality Requirements
The American Psychological Association’s (APA) Ethical Principles of Psychologists Code of Conduct says, “Psychologists disclose confidential information without the consent of the individual only as mandated by law, or where permitted by law for a valid purpose such as to provide needed professional services; obtain appropriate professional consultations; protect the client/patient, psychologist, or others from harm; or obtain payment for services from a client/patient, in which instance disclosure is limited to the minimum that is necessary to achieve the purpose.”
The National Association of Social Workers (NASW) Code of Ethics says, “Social workers should protect the confidentiality of all information obtained in the course of professional service, except for compelling professional reasons. The general expectation that social workers will keep the information confidential does not apply when disclosure is necessary to prevent serious, foreseeable, and imminent harm to a client or other identifiable person. In all instances, social workers should disclose the least amount of confidential information necessary to achieve the desired purpose; only information that is directly relevant to the purpose for which the disclosure is made should be revealed.”
Federal Confidentiality Requirements
With a few exceptions, the federal Health Insurance Portability and Accountability Act treats mental health information in the same way as it does other types of health information. Clients may sue those who violate confidentiality in particular situations, and they may face disciplinary action from state licensing bodies as a result.
HIPAA also allows a therapist to obtain a client’s consent to communicate pertinent information with an insurance provider to be compensated for claims. This normally contains simply the diagnosis and any prescriptions prescribed. It expressly specifies that the therapist should not disclose more than is necessary to ensure coverage. If a client refuses to consent, insurance cannot be utilized to pay.
State-Specific Legislation Regarding Confidentiality
Most states have legislation governing confidentiality releases. It is critical that therapists grasp the norms and regulations applicable to their location. The National Conference of State Legislatures advises all states on confidentiality regulations. Only a few states have no obligation to disclose if there is a threat of violence. The majority of states have either a statutory or permissive but non-obligatory responsibility to warn or report. Therapists need to understand the laws they must uphold in their region because of the disparities between states.
Reasons a Therapist May Break Confidentiality
Therapists are held to extremely strict ethical standards by their regulating state board. Violations can result in a loss of licensure, costly fines, and even jail time. However, there are several instances in which mental health providers are legally required to disclose something a patient says or does during a therapy session.
Here are some examples of when a therapist may be required by law to violate a patient/client confidentiality agreement and report on what they’ve heard during a session.
If a patient/client presents a danger to themselves.
If a patient makes statements to their therapist that indicate the client may attempt to inflict harm upon themselves, particularly detailed suicidal ideations, the therapist is typically required to disclose that information.
If a patient/client presents a danger to others.
If a patient confesses their desire to hurt someone, a therapist may be legally obligated to report the information provided by the client. It is not as simple as a person expressing they “want to kill someone.” There must be intent and an identifiable party or parties being specifically threatened.
A therapist cannot breach confidentiality simply because a client expresses the desire to punch, kick, hit, or kill someone in general. However, if a patient states specifics by saying something along the lines of “I would like to hurt Jane Doe by running her over with my car when she is leaving work,” a therapist is required to report this threat.
Therapists may also breach patient confidentiality if a client discloses that they are aware of an outside party who is planning an act of violence against a person or group of persons.
Failing to disclose threats to appropriate authoritative bodies can result in severe penalties for a therapist.
When a patient/client discloses abuse of vulnerable populations
A therapist may need to break patient/client confidentiality if it is revealed that vulnerable people are being threatened or abused. Vulnerable populations include children, dependent/disabled adults, and the elderly. Abandonment, neglect, abduction, physical and financial abuse all fall under the reporting umbrella.
Reports of abuse of vulnerable populations should be immediately reported to the appropriate protective services and/or law enforcement.
If a patient discloses that they are or were a victim of abuse and reveals the identity of their purported abuser, a therapist is legally obligated to reveal the abuse and the abuser to the proper authorities.
When a therapist is subpoenaed
A subpoena can force therapists to depose against their patients in rare situations. It is, however, considerably more difficult to compel a therapist to testify than it is to compel a non-licensed mental health specialist to testify. The laws that govern therapists are substantially more rigid in terms of confidentiality.
Are Children Covered by Patient/Client Confidentiality?
Children’s confidentiality is a contentious issue. Minors are not deemed developed enough in many jurisdictions to consent to therapy; thus, parents are required to agree to treatment on their behalf. As a result, children do not have the same strong confidentiality protections as most adults in those settings. In jurisdictions such as Washington, however, kids 13 and older have equivalent, if not identical, rights to seek health treatment (including mental health care) and have their privacy protected as an adult.
A breach of confidentiality can jeopardize the therapeutic partnership. An adolescent may be hesitant to disclose any information to their therapist if the child believes their parents will find out. Many clinicians ask the agreement of child clients’ parents to keep therapy private to foster rapport with the child in treatment.
Even if parents do not consent to discretion, therapists will not usually share facts about their therapy sessions. Instead, they will supply information on overall treatment objectives and progress. A therapist, for example, may note that a client has anxiety and is receiving cognitive-behavioral treatment. However, they would not be required to disclose that the adolescent is concerned about their academic performance.
Will My Insurance Provider Have Access to My Therapy Records?
Therapists will communicate specific information about your diagnosis and therapy with the health insurance provider that is financing your treatment so that the agency can assess what care is covered. HIPAA also requires the health insurance company to keep that information private. However, if you opt to pay for services out of pocket and do not request reimbursement from your insurance provider, your insurance provider may be unaware that you are visiting a therapist.
Similarly, your therapist may request your permission to share information or discuss your care with your other physicians to better coordinate your care.
Will My Therapist Inform My Employer/School of My Treatment?
Your therapist is not obligated in any way to inform your employer or school that you are seeking mental health services. Your employer will not be notified even if you utilize your company’s health insurance to seek therapeutic services.
The only way that your employer or school would be informed of your status in therapy would be if you informed the parties or if, during a therapy session, you disclosed specific threats to other employees or students.
What Can I Share About My Therapy?
As a patient, you have the right to privacy. You are free to inform your friends and family that you are seeing a therapist. It is entirely up to you how much detail you choose to disclose. Irrespective of what material you decide to share with others, therapists are ethically required to respect your privacy. Psychiatrists, for example, will not usually connect with patients on social networking sites, even though the client initiates the request.
Some psychologists believe that discussing your worries or actions with other individuals in your life might be beneficial. A therapist, for example, may want to meet your partner to further understand what’s really going on in your home. If a child is having difficulties at school, the therapist may wish to speak with the child’s teachers. However, if you include others, it is entirely up to you. Therapists are generally not permitted to consult someone else without your express agreement.
Patients should not hide anything from their therapist for fear of breach of confidentiality. A therapist is only required to report specific incidences or if they believe a person is in danger.
The majority of situations disclosed during a therapy session will be kept under wraps. The last thing a therapist wants to do is break the trust built with a patient by unnecessarily breaching patient/client confidentiality.
In other words, do not fear sharing your honest thoughts and feelings with your therapist for fear that your opinions will be shared with others. Therapy is an excellent tool for living a productive, happy, and fulfilled life.
John Cottrell, Ph.D., is a yoga instructor and certified yoga therapist in Salt Lake City, Utah, USA. He has been teaching yoga since 2000. John is originally from Oakland, California, earning his Master of Science and Ph.D. from Pacific Graduate School of Psychology in Palo Alto, California. His clinical practice led him to child and adolescent psychotherapy, drug and alcohol treatment, psychological and neuropsychological testing, and group/couples therapy. John continues his devotion to sharing health and well-being through his business, mbody. He offers private and group yoga classes, yoga therapy, workshops, retreats, written yoga articles, and a men’s yoga clothing line.
- American Psychological Association Code of Conduct: https://www.apa.org/ethics/code/
- National Association of Social Workers Code of Ethics: https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English
- HIPAA Privacy Guidance: https://www.hhs.gov/guidance/document/hippa-privacy-guidance
- The National Conference of State Legislatures:
- Informed consent: https://www.goodtherapy.org/blog/psychpedia/informed-consent