Carly’s Couch — One of the hallmarks of therapy is the guarantee of confidentiality. In this episode I break down why confidentiality is so important and explain the limits of confidentiality.
You’re listening to On the Couch with Carly. Carly’s Couch is a safe space to talk. I’m a psychologist. But I’m not your pipe-smoking, tweed wearing stereotype.
Hello and welcome to On the Couch with Carly. I am very excited to talk to you today again. Last time we spoke just generally about why people come to therapy, and I thought I would continue with trying to enlighten you about what therapy is like or what kinds of things can you expect from therapy.
I’m really hoping that this podcast will reach people who are potentially considering coming into therapy, or who are not interested in therapy but think by listening to a podcast that would be just as good. And I hope to convince you that coming into therapy is much much much more important than listening to this podcast, although you definitely need to keep listening to this podcast.
Today I want to talk to you about the backbone of therapy, and that is the concept of Confidentiality. So, one of the first things I say to anyone who comes through my door and sits on my couch, is before we even start: “You need to know everything you say today is confidential”. I feel like that really sets the tone for what sets this relationship apart from other relationships. You can talk to your friends and family about the things that are on your mind, but when you speak to a psychologist one of the most important things that psychologists offer you is confidentiality.
So that’s really the topic for today’s discussion. You know, it’s a weird thing coming to a psychologist you’ve got something on your mind, you want to express something and that’s probably difficult for you. Something that has been giving you troubles, something that is distressing. And you’ve got to come meet someone for the very first time and tell them that thing. That’s kind of crazy. I’m a perfect stranger to you and I always feel like the one thing that can help you to do that is to be assured that what you say will not leave the room in which you discuss it with me.
You know, there is something so meaningful about that. We really are the modern-day priests, we really kind of offer that confessional space. Where something can be shared that is secret, that is private, that doesn’t go any further than you want it to go. You can talk to your friends and family but you know that there’s always the chance that it’s going to be spread. And I think this really impacts on how truthful and how much you are prepared to disclose.
So, let me talk a little bit about confidentiality in terms of what I can offer you as a psychologist. So, I always say to everybody that comes through my doors: “I guarantee you confidentiality. That means that everything you say, everything I write down about you, that stays in this room. I literally leave my notes in my room, in a drawer. No one can access it. I’ve got my offices under lock and key, the only people who can access it are the psychologists who are also bound by confidentiality.
And when I say bound by confidentiality, we are ethically bound. We have completed a board exam where we are only provided our license because we understand the ethics of our profession. So, if we break confidentiality, we are actually culpable to lose our license as professionals. And that is important, this is not a little promise we give you, this is a big part of what upholds our profession and our discipline.
I also always say to my clients, there are limits to confidentiality and it’s really important to know what those limits are. For example, I always say: “You need to know ahead of time that there are going to be moments where I cannot guarantee you confidentiality. And you need to know that ahead of time so that if it happens it doesn’t surprise you. Number 1: I cannot let you harm yourself or others. I have to intervene. So, if I know, when you come to me and say to me: “I’m planning to go home and to take these pills and to kill myself.” I am ethically responsible for your life at that point. I am literally legally responsible for your life at that moment. If it is found that you gave me this information, and you went and killed yourself, I will be responsible for your death. I will literally be had up for culpable homicide. So, it’s a very very serious thing. We take suicide threats very very seriously. We always really have to investigate what you’re thinking, when you say such a thing. And if we believe that it’s a serious potential action that you’re going to take, we have to intervene. And what that might mean is disclosing something about what you’ve said in therapy. So for example, I might have to call a hospital, or call the police, or call a friend of yours. And I might have to say: “Im afraid this person has said these things to me in my office and we now have to take action”. Now that is a disclosure, that is breaking confidentiality. You are having your confidentiality now disclosed, your confidential information disclosed to someone. So that is breaking confidentiality but I’m doing it for the benefit of your safety, for your life.
That’s a very very serious thing, and I take it seriously. So, I always tell everybody beforehand: I’m here to listen and I will always keep your information private, and I won’t share it with anyone. But, if I feel that you’re in danger or you’re about to harm yourself. you are not prepared to take responsibility for that. So I say to you, you have to go to a hospital and admit yourself. And you say no, then I will disclose that information to get you the help you need.
The other thing is if you’re going to harm another person. So this is where this gets really tricky.I dunno if you’ve ever seen The Soprano’s. But I don’t think that was correct the way that psychologist knew about murders and she didn’t really do anything about it. If you know someone’s going to get hurt, you actually have to intervene.
And this is quite a pertinent thing in South Africa because we have this huge rate of HIV, and it’s actually something that we studied in our board exam. It was like a specific question you had to answer. But there’s a whole procedure involved. If they tell you that they’re HIV positive, and are having unprotected sex, then you ethically should intervene because you know someone’s life is at risk then.
And there’s a whole procedure that you have to follow. So first and foremost, if something like that happens, you have to first talk to your client about it. You have to explain the limits of confidentiality, and you have to decide together how to go forward. But the outcome has to involve mediating that danger or that harm to the other person. If the client is not prepared to concede or won’t change their behavior, and doesn’t want to disclose themselves. You have the ethical responsibility as a psychologist to do the disclosing. To find that person and to make an effort to show that you are protecting their lives.
It’s very tricky stuff, and to be honest I have never had to do it myself. But I always tell people this ahead of time, so that they know when they say: “I’m serious about confidentiality.” There are real limits to it. Other than these limits, I am going to keep your information safe and protected.
The other big thing, it’s not just whether you’re harming yourself or others. But the other big thing that I have to look out for is whether any of the information you reflect on in our sessions shares the fact that a child is being hurt, abused, mistreated, neglected.
The Children’s Act in South Africa is really clear that we have to uphold and we have to protect the rights of children, at all costs. So, when you come as an adult to my therapy room and I help you and I think through your problems. Even if you are struggling with the fact that you are abusing your child, that there’s something going on that is really problematic. Of course I am here to help you and think through that but I also have to protect the children that are at risk. So it would be my duty to fill out a form- and there’s a specific form that you have to fill out. That then will go to social services, so that social services know to watch this family, to keep an eye on them, to keep an eye on the children and their well-being. Because if I don’t do that, I’m not taking care of those children. I’m not being responsible for them and that is my mandate.
So I always tell people, right at the beginning when we start talking: “ These are the rules. I can offer you 100% confidentiality, however, if I hear that you are harming yourself or others, or if I suspect a child is being harmed. It doesn’t have to be that the client is harming the child, even if they know of another person who’s harming the child. I have to take action about that because I’m responsible for children above all else.
And I think that’s a good thing but it can result in some tricky situations with clients, and I have dealt with that in the past.So I have actually experienced having to contact social services and have a social worker go look at a family who I think is in trouble. And it’s a tricky thing but one that I take very very seriously.
So, the other major way that confidentiality may be breached in the therapy process. It doesn’t happen often but it has happened and can happen. That if you as the client go into some kind of court process. So, if you commit a criminal offence or maybe even if you get a divorce, and your character is called into question. It has been known that a lawyer can ask for the case files of the psychologist to be subpoenaed, to be used as evidence in the court of law. Although you can refuse to provide those to lawyers, you really can stand your ground and say no these are confidential and `I can’t, because that is possible. But sometimes the judge will overrule and say that it actually is necessary to provide those documents. Although this has never happened to me, and I have never known of anyone it’s happened to.
We’re just told that your notes can be subpoenaed. So, it’s actually quite crazy, we have to keep notes of all our clients because in case something comes up at a later stage. It can actually be very helpful. Some clients may actually ask us to disclose their client notes, if they feel it could assist their case. At the end of the day, it’s only the client that give you consent to disclosing that information. If a client asked me if they could use my process notes for legal purposes. I would have to get a consent form that they would then have to sign, and provide written consent that my notes can be used. If it’s not for the client’s consent, there’s no way I will hand it over. Unless a judge forces me to.
So, those are the limitations of confidentiality, which for me entrenches what a serious thing confidentially is and how important it is to therapy. I think it is so so important that it really is the backbone of our work. It provides the grounding/framework of how all the work that we do, kind of, is built on. And if you think about why confidentiality is so important for a client is that, as I said before, you come in with this perfect stranger with your deepest, darkest material, all the stuff you kind of don’t want to tell anyone else, hence why you’re speaking to this stranger. And I think the fact that you’re offered this private, safe, confidential space really does aid the sense of of safety and it reassures you that this kind of stuff that you don’t want people to know about is not going to go anywhere and it’s going to be safe and it’s going to be protected.
The thing about confidently is that it makes my job really weird. Let’s be honest, it’s not many jobs out there that you can’t talk to about anyone else. And that’s what so crazy about the work that I do. I love my job and I’ve got the great privilege to work with people’s stories, and sharing their pain, and trying to bond with them and work through difficult moments. But I cant go back at the end of the day, and tell anyone about how hard my day was, what was the content of my day. I can’t ever explain to someone why I’m feeling tired at the end of the day. I feel okay holding onto people’s private information, it’s not something I struggle with. I think I’ve learnt and honed my skills over the years that now it’s something I can hold in the moment. Then when I leave the office, I generally leave it behind, and I go back home and I’m not carrying everybody’s stories with me. I think that would be way too much of a heavy load but every now and again you have a bit of a bad day, everybody has a bad day at the office. And it can be frustrating and is definitely a bit alienating and a bit lonely that you can’t come home and express to someone about what happened.
The thing though is that I do have a clinical supervisor, and my supervisor helps me a lot with that. So, I take some material to her, the difficult material that I have to work through and she as a psychologist herself is also bound by confidentiality, so it’s ethical for me to share with her my clients information because she also won’t share it with anyone else. And together we can think through the client’s problems. You know:” Two heads are better than one”. That kind of thing. And it’s really helpful and it’s really nice to have someone who’s more senior, who has a lot more experience, who’s is well-read, who understands the stuff, and also has the perspective-she’s not in it with me. She really gives me the amazing support that I need. Psychologists should also be in their own therapy. Mostly just so that there is someone else thinking about their needs, their feelings, you know “Their stuff”. So that we’re not bringing our stuff into the room with us. It’s so easy in therapy to get caught up in the emotions of a process. I’ll get into this a little bit more when I talk about this in a later episode, but really as I said in the first episode the work that I do, I think of it as being from a relational perspective.
So, that means I believe that you and I are in the room together, and we’re forming a relationship. And so, how I feel about you, and how you feel about me is just as important as how you feel about your mother or your father, or anyone that you speak about in the session. It’s this relationship that we can also use to make sense of you, and make sense of your world. And so, I’m in this relationship with you, and sometimes clients can say things that trigger you. That makes you feel a certain way. It’s really important that you’re doing your own work privately, that you’ve got your own support and your own therapeutic process. That you can kind of fall back on to help you make sense of what’s going on for you. I think personal therapy really helps with that. So, I always suggest for therapists that they should be in their own therapy process, as much as possible. And supervision as well, is great.
And you could also do peer-supervision, which is great. Which you can talk to other psychologists about your work. You know, anyone who is a psychologist is bound by confidentiality. So, you can reflect on clients with them, you can disclose more to them. I wouldn’t necessarily, still disclose details because I’m very very private about my client information. I actually don’t like sharing client information even with other psychologists that I may meet. But if you’re in a peer-supervision process, where everybody signs confidentiality agreements you can use that case to speak a little bit about to what you’re dealing with.
If you are in some academic process, then you can disclose some information but not others. So, you might speak about 41 year old male. And you might speak about, “ In an accounting firm,” rather than saying his name and he works for whatever company, I can’t think of an accounting firm right now. So there are ways to talk about the work with other professionals, but it’s not the same as if you know the person that you are talking to. Like a discussion with your partner, or your friend, or your parent. Then you would usually, if you’re in a normal job, you would come home and would use people’s names and you would speak about the intricate details of what went on. He said “this” and she said “that”, “That’s why I’m upset”. Whereas, you can’t do that with this work. And it is, it’s a bizarre thing that I work with people and nobody knows what we talk about. But it’s cool, I think it’s the most important thing that I can think of on what I can offer you as a client. Is that this information is not shared with anyone, and that you’re guaranteed this private, confidential space. I would say the times that it’s the trickiest to be quiet about who you working with, as in when you’re working with a celebrity, or someone whose famous, or that other people know, who’s in the popular media or something. And I have had that once or twice. It’s funny because there’s times when something will come up and you have the urge to go “Ooohh”, and you just cant. In a way it’s kind of cool, you’ve got this private relationship with someone who everybody thinks they know. And you know something. But you can’t tell them. Well it’s kind of cool and it’s kind of challenging.
So, that’s really all I want to say about confidentiality today. Just introducing this concept, I thought it would be interesting. As a way of, kind of introducing the idea of therapy, and how it’s different from another relationship.
I would like to talk more about the different aspects of therapy, as we go forward. And talk about my approach and how I think about therapy, and people and emotions, and just the WTF of life.
So please stay tuned. You’re welcome to continue the conversation with me. So, I’m happy for questions or comments after you’ve listened to this. You’re welcome to go onto my Facebook, or my instagram or even my blog or website and email me directly. Basically the podcast is On the Couch with Carly, and that’s also the hashtag [#onthecouchwithcarly], that’s also my instagram handle, that’s also my Facebook page. So, hashtag @onthecouchwithcarly. You can also email me info@onthecouchwithcarly or carly@onthecouchwithcarly. I’d love to hear from you. I’d love to hear what you’re thinking, and what of this is interesting or relevant to you. Or what would you like to hear about or maybe you’re interested in a particular aspect I just glided over, you want know more about that. So, that’s all for today. I hope you enjoyed this episode of On the Couch with Carly. Catch you on the couch next time.
This podcast is recorded at Edible Audio in Cape Town, South Africa. Edited by Edible Audio. Original music by: Alex Smillie