Can you keep a secret?

One of the reasons that people seek out professional counseling instead of just talking to people already in their lives is that the conversations are confidential. While some people find talking to strangers uncomfortable, others find it liberating to be able to disclose details of their lives without the knowledge and involvement of other parties.

While an ethical mental health professional can be trusted with sensitive information, it's important to know the limits. The nature of their work means that they will encounter sensitive information that occasionally must be acted upon. Each therapist should provide information on when confidentiality must be broken before treatment begins. If this is not done (or if it's been a while and you've forgotten), ask your therapist to give you a copy of her policies. 

In general, the exceptions apply in these four situations:

1. Danger to self or others

If you threaten to hurt yourself or another person, your therapist will have to evaluate what actions are appropriate to keep all parties safe. Factors such as the the presence of an exact plan, directness of the threat, severity and the ability to follow through with it are all taken into consideration.

Don't hold me to these, as this is not an exact science, but here are some examples:

Should not report: 

"I'm so mad at my husband that I wish he'd get hit by a bus." 

"I wish I had a gun so I could shoot myself."

"If I catch my wife cheating again, I'll kill them both." (Contingent on followup questions suggesting it's a sentiment, not a plan.)

Should report:

"I bought a bunch of pills and alcohol so that when I go to bed tonight, I'll never wake up."

"I carry a knife so that when I see him, I can stab him repeatedly."

"After this, I'm gonna head over to my uncle's house and take care of him for good."

A threat of harm to self can be responded to as needed in the situation, ranging from calling a friend to come over for the night to forced hospitalization. As far as threats to others, law enforcement will usually be contacted, although the potential victim(s) may as well. Past crimes aren't held to the same standard as imminent threats, with a couple of exceptions.

2. Child or elder abuse

Because children and elders are considered vulnerable populations, reporting abuse and neglect of these groups is an obligation by law. Some states require everyone to be mandated reporters while others limit the duty to both therapists and some other groups, which may include teachers, health care professionals and law enforcement. 

The appropriate course of action is that when there is a reasonable suspicion of abuse, a report is made. The reporter gives relevant information to another agency, which then decides what the appropriate course of action is. Information leading to a report does not necessarily have to come from the victim or even be a verbal confession. A child with cuts and bruises of different ages with no compelling explanation, a mother who mentions her boyfriend's mistreatment of her son and a teenager mentioning that her underaged friend is a victim of incest are all cases that will most likely be reported. An adult discussing abuse from his childhood, however, will probably not require further action unless, for instance, he has a younger brother who is in the same environment and is likely to be abused as well. A therapist is also not forced to report situations between adults, such as domestic violence in the home of a childless couple. 

The same standards will often transfer to elders and possibly disabled individuals. 

If you have questions about reporting abuse, receiving support or available services, call 1-800-4-A-CHILD (1-800-422-4453). This will not create an official report, but the people on the line can help you find out the next steps. If you are unsure about a situation, please call. It's not a commitment and it's okay to just ask a question.

3. Court order

Occasionally, mental health professionals are asked by the courts to provide information about their clients. This does not mean that any time someone is arrested, the therapist is called to confirm the offense. The principle of confidentiality is so important to therapy that mental health professionals will only reveal the least amount of information required of them and only when presented with official orders. There are also limitations on what can be asked of them, as it has to be relevant. In a murder trial, your therapist can be asked to confirm that you confessed to being at the crime scene, but probably won't answer about whether or not you're having an affair (unless it's directly related to the case). 

This exception rarely comes into play, but it has to be mentioned. The point of therapy is to help you get better, so that should take precedence over the possibility that some day five years from now your therapist will be called upon to answer if you smoked some weed. (She won't.)

4. Medical records

A limited amount of information is given to your insurance company in order to qualify you for treatment. This usually is a diagnostic code showing what you are receiving treatment for. It's not comprehensive and it doesn't involve details; it's just a way of indicating what you are receiving treatment for so that they can cover you. This is a current issue, though, and if this is a concern, learn more about what is required in your area and by your insurance company.

Outside of this, your information may be disclosed to other health care providers with your permission. This will require you signing forms and you get to specify what, exactly can and can't be released and for how long. This applies to the medical field in general, so if you want your wife to be able to get your test results for you when you aren't at home next week, ask for the paperwork!

The topic of mandatory reporting is not without controversy, but these are general descriptions of the current standards. Please don't be afraid of opening up because the information may get out. Breaking confidentiality unless it's absolutely necessary would ruin the whole point of the entire field, so it's an ethical (and legal) obligation that is taken very seriously. 

If confidentiality is a concern, talk to your mental health professional. He'll be able to give you more information on local laws and his own stance on these issues.