TRANSCRIPT
A big part, or maybe the biggest part, of what makes psychotherapy have the potential to be such a beautiful thing in someone’s life, to really help someone grow and change, is confidentiality. Meaning what they tell to the therapist will not be shared beyond the therapy office. The therapist is bound by confidentiality. Whatever happens in this office stays private. It stays in this room, and the confidentiality is sacred.
And that’s very, very hard for a therapist. Sometimes it’s hard to hear very painful, difficult, scary things, emotionally overwhelming things, and to keep it to oneself. I was a therapist for 10 years. I heard tons and tons and tons of stuff that was not easy to hear. The kind of stuff that if a lot of people hear, ooh, I don’t want to hear anymore. Too much information, or this is scary, overwhelming, gives you bad dreams. It can make it difficult even to want to listen to more information. That’s part of why the job of a psychotherapist is so difficult—to just really sit and listen, to be there for someone when they are sharing things that can be pretty extreme, very overwhelming, so private, so intimate, scary, perverse, illegal even.
Well, having also been a psychotherapy client, I loved confidentiality. It, for me, is what allowed me to feel safe to talk about myself in psychotherapy. However, I didn’t really trust my therapist so well. I didn’t trust that they weren’t talking about what I was telling them with other people, and I think I was wise to not trust them.
Then I became a therapist. I worked in a lot of different contexts. I worked in community mental health clinics, worked for a while in a mental hospital, worked for the last six, seven years in private practice. And so I got to explore the subject of confidentiality from the perspective of a therapist, from different angles. And what I came to realize is, although more than ever, the longer I became a therapist, the more I passionately fought for confidentiality, believed in it, held it to be a cornerstone, if not the cornerstone, of psychotherapy, I saw how the mental health field actually doesn’t take it that seriously a lot of the time.
They don’t admit that they come—don’t come right out front and say that. Most therapists don’t come right out of—right up front and tell their clients these are the limits of confidentiality. And there are lots of limits. Maybe they’ll give them a little lip service, the limits, but really it’s something to really be aware of as a psychotherapy client going into therapy because people can get burned really badly if their confidentiality gets broken.
Basically, what it is, is when confidentiality gets broken, that is a betrayal on the part of a therapist. And the mental health field often says that that is okay. So let me talk about some of these limits.
Well, probably the most overt, obvious, big one, that’s that some psychotherapists even go up front and tell their clients because it’s part of the rules, it’s part of the code of ethics of being a therapist, is the subject of suicidality. When a psychotherapy client has suicidality, is thinking about killing him or herself, wants to kill him or herself, has a plan, has intent, and that’s how the psychotherapy field grades the intensity of suicidality.
Is there suicidal ideation, meaning just thoughts and feelings about it, musings about suicide? That’s the lowest level. Then there’s, do you have a plan? Do you have a way in which you’re going to kill yourself? And then do you have intent? Are you going to go for it? Are you really going to do it? Is this person really imminently suicidal? Are they really at risk of taking their own life?
Therapists are tasked with trying to figure that out, trying to make sense of it, trying to determine is this person really a danger to himself or herself? And if the psychotherapist determines that there is a real risk of the client killing himself or herself, he is required—the therapist, he or she is required to break confidentiality, meaning to do something about it, to put this person in the hospital, to call, to tell a supervisor, to do something, call the police, to do something to stop this client from killing him or herself.
And while what I’ve seen is most psychotherapists actually argue that this is a good thing, I personally don’t, and I’ll tell you why I don’t. While most psychotherapists argue that it’s a good thing, the code of ethics says it’s not just a good thing, it’s a necessary ethical thing. All the professors that I ever had when I was a social work student all said this is important. You have to do this. All my supervisors believed in breaking confidentiality if someone was really a risk, if the therapist determined this person was a risk to him or herself.
Why do I not believe in that? Well, the main reason is I have just personally witnessed so many examples of psychotherapists being anxiety-laden, being terrified of someone killing themselves, being so afraid that someone’s going to kill themselves, and not just afraid for the client’s sake, but afraid for the therapist’s sake. Oh, if somebody kills him or herself, I’m going to get in trouble. If a client of mine has a suicide attempt and I don’t do something about it, I’m going to get in trouble. I’m going to be liable. I could lose my license. I could lose my job. I could get sued. I could feel bad. I could feel guilty.
And what that leads a lot of therapists to do is to be trigger-happy, to call 9-1-1 quickly, to call the police quickly, to do something quickly to stop something that might happen or might not happen. And so what I have seen, and more heard stories about, is psychotherapists getting so terrified of someone killing themselves, and I’m going to even use the word paranoid because it’s an irrational fear, that they end up putting people in the hospital and calling 9-1-1, getting people sent to the emergency room, getting cops and ambulances coming around people’s homes just because someone said a musing, a thought, and the psychotherapist didn’t know how to determine it. They weren’t really able to read the motives of the person they were talking with.
And a lot of times people come to psychotherapy and they talk about how they’re feeling. And guess what? What I learned as a therapist by listening to, I don’t know, hundreds and hundreds of people over 10 years, 15,000 psychotherapy sessions with hundreds of different clients, is that at some point in the psychotherapy, probably most clients experience some degree of suicidality. Suicidality in this modern, crazy world, with so many people being traumatized, so many people being confused in impossible situations, difficult, confusing situations, not knowing how to move forward, feeling suicidal, it’s kind of normal, especially in psychotherapy when people are being the most bluntly honest.
People are told when you come to psychotherapy, take off your filters, say what you feel, say what you think, don’t censor yourself. That is what makes psychotherapy work. And yet therapists sometimes don’t know how to handle all this information, especially new therapists. I’ve heard that. I’ve heard interns panicking, really panicking. And often they’re not panicking in the session. They hear—they think the person is doing a good job talking about suicidality. But after the session is done, an hour later, two hours later, the psychotherapist goes home, four hours later they’re sitting at home at night, and they realize I didn’t really properly assess for suicidality. I know the person was talking about having suicidal feelings, but maybe they really do have a plan. Maybe they’re killing themselves right now. And they panic, and they do something, and then they call 9-1-1 or they call their supervisor.
And the supervisor, of course, is usually going to say, oh my gosh, if you don’t really know, you have to do something. If you didn’t fully assess, if you didn’t ask, if you didn’t have a confident response on the part of the client that assuages your terror and your fear, you got to do something. I’ve seen that happen at therapy clinics. I remember sitting—it probably happened four, five to six times over my time of being a therapist at different clinics, sitting in my therapy office, waiting for a client to come. The door is open, and suddenly police come walking by, ambulance workers come walking by, sometimes holding one of those flat beds that they strap patients to. And I’m like, what is going on? Oh, a therapist down the hall called 9-1-1 on a client right in the middle of session.
I’ve heard this from the therapist, and I’ve heard this from many, many people who were psychotherapy clients. They’re sitting in the office, talking to their therapist. They’re sharing, yeah, about being really depressed, having some suicidal feelings. Not necessarily even anything extreme, the kind of thing that I might have heard regularly and just not even been worried about. But the therapist didn’t know how to assess it. It was overwhelming. They were not that experienced, or sometimes maybe a therapist had gone through a suicide with a client, had a past client kill himself, and now the therapist himself or herself is traumatized and becomes trigger-happy and no longer has a rational ability to assess what is going on and panics when something comes up that kind of resembles what may have happened in the past.
And so what they say is, “Excuse me, I have to go to the bathroom,” or “Excuse me, I just have to step out of the office for one second.” And the client’s like, “Okay.” And the client’s sitting with his or her thoughts, and the next thing you know, the door opens and the cops are there because the therapist went out and called 9-1-1, or the therapist went out and asked a supervisor. The supervisor is like, “Yeah, you got to call 9-1-1 if you’re not really sure.” Or sometimes the therapist can interpret things or share it with the supervisor in a rather extreme way and make the supervisor get anxious because sometimes the supervisors can pick up on the therapist’s anxiety.
I’ve also heard this one: the client doesn’t even know the therapist has a supervisor, never even thought about the concept of a supervisor. So this also goes right into confidentiality because when a therapist tells something specifically about a client to a supervisor, isn’t that breaking confidentiality also? Especially if the supervisor has access to the client’s charts, which they do. They know their name.
Well, I’ve heard this happen also. Therapist steps, okay, client says something about feeling suicidal, not necessarily any imminent intent or plan, no real desire to kill themselves, just musing, sharing about pain and feelings. Therapist gets nervous, gives some fake reason why they have to step out, steps out of the office, goes to talk with the supervisor, and the supervisor says, “I cannot determine it from what you’re sharing. I need to talk to the client.” So suddenly the therapist returns with this random person. “Who is this person?” says the client. That’s walking into my private psychotherapy session at an extremely intimate moment, no less, where I was just sharing about some of my most terrifying feelings of maybe not wanting to be alive, existential terror, fear, sadness. It’s very healthy and normal for clients to talk about their existential despair in psychotherapy. What better place to do it? And yet sometimes the consequences can be terrible.
And suddenly there’s this random person. “Oh, this is my therapist supervisor,” who shakes my hand and gives their name. I didn’t even know this person existed. And the next thing you know, this person is interviewing me, asking me questions about my suicidality. And suddenly the client can realize, “Oh, [ __ ]! I’m in trouble. If I say the wrong thing, I’m going to the hospital.” And sometimes it happens. Cops come, take them out, put them in a straitjacket. The next thing you know, the person’s in the emergency room, ending up traumatized. I’ve heard that again and again from clients. Usually, they don’t want to go back to the therapist. Sometimes they’re forced to go back to the therapist. How does it feel to go back to a therapist who ratted you out, who called 9-1-1, who got you stuck in the hospital, maybe got you injected with medication? Not fun.
Now to argue it from the flip side, well, maybe it is the job of a therapist to prevent suicide, to get someone to go to the hospital. I say I never called 9-1-1 on anyone, and I heard tons of people talk about having suicidal thoughts, having suicidal feelings, having plans, and sometimes even having intent. People who would be considered imminently suicidal. Well, I made a whole other video about that recently. I guess I can link to it in the description box below about how to work with people who are really suicidal as a therapist. There are so many different ways to work with a client who is imminently suicidal: plan, intent, ideation, all of it, without breaking their confidentiality.
I’ll be really quick. You can see the person a bit more. You can work with them more intensely. You can have longer sessions. You can lower their fee. You can check in on the phone more. You can be a better therapist. You can be more caring, much more compassion, much more empathy. Also, make it clear that you’re not going to break their confidentiality, that this relationship is so sacred and so honored by the therapist that you really believe you can help this person. Even that through the nurturance you’re providing, you love this person.
And what I’ve seen again and again and again, my experience as a therapist is when people are in an extremely imminently suicidal place, when I, as a therapist, and I’ve heard other stories about this, when a therapist really devotes himself to the confidentiality, to honoring the relationship, to working with the client more intensely, seeing them more, believing that they can come out the other side, people from what I’ve seen don’t kill themselves. Maybe it will happen once in a while, but maybe this person is going to kill themselves no matter what.
I’ve also seen that therapist breaks confidentiality with the client who is feeling suicidal. Client goes to the hospital, has their confidentiality broken, feels betrayed, and then kills himself in the hospital or when they get out of the hospital. So what I think is breaking confidentiality is probably more likely to lead to suicide. The other thing is if clients realize that if they say the wrong thing and they can get themselves put in the hospital, get the cops called, get the ambulances called on them, they’re going to share less in psychotherapy. Who wouldn’t do that? I certainly thought there are certain things I probably won’t share with my therapist and don’t want to because I don’t trust them.
So especially once someone has had the police called on them, get forced to go to the hospital because of intimate things they shared with the therapist, do you think they’re going to trust a therapist so quickly the next time? No, and I don’t blame them at all. The other thing is if people don’t trust the therapist so much, aren’t so open, aren’t so willing to share how they’re really feeling, how much can psychotherapy really work? So that’s the thing. All this is supposed to protect the client and protect the integrity of the client’s life and protect the integrity of the psychotherapy, but often it can work in the exact opposite direction by having the therapist be in a position to be an agent of the state in a way, an agent of outside forces who are here to stop the client from having their independence and freedom.
It lowers the sanctity and sacredness of the psychotherapy such that if the client can’t be more honest, they can’t get as much help from the therapy.
Well, let me jump into another area where confidentiality is so often broken, and that is team meetings. It happens in therapy clinics, but it happens way more in mental hospitals where you get the entire team together. You can get 20, 30 staff members talking about a client, a patient, who everybody knows who they’re talking about. They’re using their name, and they’re talking about their most personal information. I talked about this quite a bit in a video about why I didn’t like working in mental hospitals, so I don’t really need to repeat myself so much now. But suffice to say, zero confidentiality. People’s most personal and intimate information, when they’re getting their period, how often they masturbate, suicide attempts, relationships, their sexually transmitted diseases, all being shared in a very public format. Sometimes in places where the clients can even walk by and look in the window, and if they were lip readers, which by the way, there are clients who are deaf who can read lips, they can see what’s going on. They might even guess, or if they haven’t forbid, have paranoia, which is not uncommon. Therapists have it too, that they can think that they’re talking about them, and they’re probably true at certain points. And it’s like the clients are getting dissected for public consumption, and sometimes, to be honest, it’s for entertainment value because a lot of times.
I think staff members show up just to listen to the morning gossip session. They’re not out for the benefit of the client, and they love the breaking of confidentiality.
And then what are those called? Case conferences, where the therapist or a psychiatrist gets up in an auditorium and talks openly about the client’s situation. And then brings the client up on stage, so an audience, sometimes of just people who work in the hospital, or maybe people who just snuck into the audience, are listening to the breaking of confidentiality while the patient’s sometimes sitting there being interviewed, having their personal life analyzed. Or sometimes they’re told to leave.
They share their identity in their face, and they’re standing there in a pair of pajamas. They’re sitting there in a pair of pajamas. Then they get sent back to the ward knowing that everybody in this audience is going to listen to a dissection and analysis of their life, of their most humiliating and private things. And this is considered okay. This is considered good teaching. This is considered—we’re breaking confidentiality, though they don’t use that word. We’re sharing this person’s personal information because it’s a teaching hospital to help other clinicians learn.
Even though maybe it’s just the janitor of the hospital sitting there, maybe it’s the cook in the hospital, maybe it’s a stranger who managed to wander in or get invited in just to listen to all this personal stuff. So it makes me really wonder how in the world in school could they tell us that confidentiality was sacred when the field itself so often treats it as not sacred.