In principle, the therapy room is "Las Vegas:" What happens here stays here. Well, almost.
If you're in therapy with a licensed therapist in the state of California, your therapist has (or should have) already told you that there are a few instances where he or she must break confidentiality in order to address an issue of safety. These instances are:
1. If you tell me that you're going to harm yourself. On occasion, you may have heard many people say in a moment of frustration, "I could just kill myself." Often, this is just taken as a figure of speech, and passed over with no real concern.
However, in the therapeutic setting, even if I really don't think you're serious, I'll discuss the comment with you to understand if you're serious, somewhat serious, unsure or not serious at all about harming yourself. I take any comment about harm to self or others very seriously, until I'm sure there is no reason for concern.
The standard for reporting a client's self-harm is "reasonable suspicion," that is, if, after talking with you directly about your suicidal thoughts and/or plans, your therapist has a reasonable belief that you are going to hurt yourself, your therapist is obligated to call someone to help keep you safe. Before breaking confidentiality, your therapist may attempt to have you agree to a no-harm contract. If this is not successful, or if your therapist believes that you are not sincere in making the contract, he or she may call in the police, paramedics or other emergency response team trained to assess for suicidalitiy.
If these professionals feel you are an imminent danger to yourself, they may initiate a "51/50" which allows you to be taken to a safe place for observation and treatment. The length of the hold will depend on the assessment of the mental health professionals involved.
2. If you tell me you're going to harm someone else. Again, a frustrated person may blurt out in anger, "She's such a jerk. I could just kill her sometimes!" Again, I take the words seriously, and will assess to see if there is any reason to be concerned. Like the scenario for self-harm above, if I have a reasonable belief that you are an imminent danger to another person, I have an obligation to notify that person (if at all possible) and to notify the police.
3. If you tell me that a child (under the age of 18) is being physically or emotionally abused. This child doesn't necessarily have to be in your family. I have an obligation to try to identify the child and make a report to Child Protective Services (CPS), or any similar agency in your community. Physical abuse includes certain forms of hitting, using excessive force in any way and/or sexual abuse. Emotional abuse involves repetitive and degrading behavior, often verbal, designed to intimidate and demean the child. Again, I don't have to have "proof" that there is abuse, just reasonable suspicion. It will be up to CPS to determine if an investigation is warranted. If so, they will usually make a visit to the home or school to gather more information, clarify facts, discuss the situation with the child's family or legal guardians and take any corrective action needed to keep the child safe from physical or emotional harm.
4. If you tell me an elder (aged 65 or older) is being physically, emotionally or financially abused.
Again, this person doesn't necessarily need to be related to you. The criteria for physical and emotional abuse are virtually the same as for children. Financial abuse has to do with unwanted interference with the financial dealings of an elder, theft from assets, cash or accounts, or negligence in the management of an elder's financial matters. As with all instances listed here, I don't need proof. This will be up to a team of investigators from Adult Protective Services, or a similar agency in your community. Like the other scenarios listed above, I'm required to report a reasonable suspicion of these kinds of abuse with elders.
5. If a judge orders me to release your client records. While it has never happened in my practice, on a rare occasion, a judge will compel a therapist to release confidential psychotherapy records. It can sometimes happen when couples who are divorcing or contesting child custody ask their attorneys to subpoena family psychotherapy records.
I am only authorized to release your records (or any requested information about your treatment) if 1.) you provide me with a written, signed release stating that I may do so, or 2.) a judge overrules my attorney's objections to release your records and orders me to provide them to the court.
Currently, these are the specific instances I'm required to report to authorities, and all are directly related to human physical, emotional, or financial safety.
What about domestic violence? Currently, there is no mandate to report incidents of domestic violence between adults. While I may work with you to help you decide how to stay safe or access resources so you can ensure the safety of yourself and your children, I cannot, by law, break confidentiality in this instance.
I've been fortunate. I have never been compelled to release client information. On rare occasions, my clients themselves have asked for very specific information about their treatment to be released. I will only release this information if I've had the opportunity to discuss this with my client so that we both can adequately understand the ramifications of release of such information.
A good therapist will freely discuss with you the limits of confidentiality in therapy. If you're not sure, ask. Neither you nor your therapist should leave disclosure up to a roll of the dice.
Until next time, thanks for listening.
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