T3 - Therapy Basics: Confidentiality

It's come to my attention that I should do posts on some of the basics of therapy. As often as therapy comes into play in our novels (either a character receives/should receive/did receive therapy, has to take a friend to a therapist, etc), maybe some understanding of the mechanics of my profession will help bring a sense of authenticity to what you're writing about.

So my first Thought will be on confidentiality.

What is it?

Confidentiality is a an ethical concept. Legally, I'm required to present the parameters of confidentiality to a client prior to the onset of therapy. They need to know what's not covered before they agree to participate. Most everything (I'll qualify this more later) disclosed between a therapist and client is confidential; that is, I can't just go telling anyone what a client told me in session. It's considered privileged information, but this is actually a legal term I'm not going into on this post.

I can't share anything from our sessions unless I have a client's express written permission (or in the case of multiple clients--like a husband and wife--a signature from all involved parties). Verbal consent can only me used in emergencies, and all therapists would have a form for this express purpose, usually called a waiver.

Who/what does it cover?

Confidentiality is very extensive. If you tell me you have $1000 in outstanding parking tickets, I can't pick up a phone and call the local police station. If you bring in photo albums or journals to share, the information in them is all covered. If you tell me you committed murder (or some other crime), I can't call the cops to come get your murdering self.

Many times therapy is between more than just one person and the therapist. In that case, everyone is covered. For example, a husband needs proof that he attended anger management sessions for his job, but his wife attended some sessions with him and some of what he's requesting came out during one of those sessions. I'd have to get the wife's consent, as well.

Many times, other professionals are consulted on a case. Say, a client needs to have a physical check-up to rule out some medical reason for depression. The results of the exam are given to the therapist, and this is kept confidential.

What's not covered?

It is not a blanket cover indicating that whatever goes on in the session will be kept between the therapist and the client no matter what. Basically, there are three scenarios where confidentiality would not be upheld in (i.e., legally, I'm mandated to report to authorities if the following scenarios crop up in therapy):

1) Client poses a danger to himself. Suicidal clients have to be treated with extreme caution and care. The therapist, acting on behalf of the best interests of the client (in the therapist's expert opinion), would reveal certain information to a crisis response team or a psychiatric hospital or possibly the police in order to ensure a client doesn't harm him or herself. A suicidal evaluation would be done by the therapist to discover if the client has a plan to kill themselves and how strong their motivation is (i.e., how lethal is the plan and how accessible would someone be to help?).

2) Client poses a danger to someone else. Homicidal tendencies can come out in therapy. I'm not necessarily talking about a a scorned woman's comment through her tears, "I'll kill the witch if I see her!" However, even this type statement should be looked into further by a discerning therapist. If the therapist has reason to believe truth to a statement, then he or she would have to further analyze the means, motivation and method the homicidal patient might have to see how big the threat is. Then information is disclosed to authorities accordingly.

3) Client reveals a known or reasonably suspected case of elder/child/dependent adult abuse or neglect. The three groups mentioned in #3 are all protected by special laws. For elders, the abuse could be financial or geographical (isolation, refusing mail or to allow friends over). For all three groups, abuse could be emotional, physical, mental, or sexual.

Even if the client reports hearsay, the therapist has to report. "My neighbor told me his kid's best friend was abused. I guess you can never be too careful." All the therapist needs is a "reasonable suspicion" to disclose information. In the above scenario, I'd have to call the authorities and report what information I could gather (name of the child abused, where it happened, etc).

What about minors?

Disclaimer: everything I'm about to write pertains to California laws concerning minors. It does vary from state-to-state.

A minor is entitled to a confidential relationship even if they aren't the paying party. It behooves the therapist to form a contract with the payer (i.e., parent) at the beginning of treatment to determine what will and will not be disclosed to the payer. Parents are legally entitled to any and all information based on the minor's best interests, but LMFTs are obligated to maintain the minor's confidentiality. (I mean, come on. How many teens are going to open up to a therapist if they knew the therapist was parroting everything back to their parents? Hardly makes for a bonding, therapeutic relationship.)

So the therapist has to balance their ethical duty toward the client (minor) with the legal right of the parent. The best way to do this is for the therapist to first try to talk to the minor first, and urge them to consider sharing pertinent information with their parents. If that doesn't fly, then the therapist can ask permission from the minor to share the information with the parents with or without the minor in the room. If that doesn't fly, then a summary would honor the parents' rights to access the records while protecting the best interest of the client. This way, if a father requested info, you could leave out, for example, the fact that your client said he hated his father when you give a summary.

Well, that sums up confidentiality. Hopefully it wasn't too boring, but this kind of information could be very pertinent at some point to a WIP! :)

If you have any other questions about more specific confidentiality things, lemme know in the comments section and I'll do my best to ferret out an answer for you.

Treatment Tuesday - Doctor/Patient Relationships

We've got a great question on the therapeutic table today, people! The writer, who wishes to remain anonymous, wrote in with a blurb about her book. Molly* sets her sights on hot young psychiatrist Dr. Wade Williams.* She makes about four trips to his office for “evaluation,” even though she’s feigning her symptoms. The author has lots in store for Molly and Wade, but the gist of her dilemma is that Dr. Williams stops his evaluation of Molly and then enters into a relationship with her. She’s afraid the reader might think Dr. Williams is being unethical, but in the final scene (**SPOILER**) he informs Molly that he never took her on as a patient.

* Names have been changed to protect the fictional.

Here’s the real question:

It was brought to my attention it is against the law for a doctor to date a patient for two years or something to that effect, but I took artistic license and played the story out the way I wanted to. Is this a believable plot line (in the realm of romantic comedy fiction)? Or am I staring down the barrel of some serious issues here?

What a packed question! Let’s try to unravel it today.

First off, whoever brought it to your attention that it’s against the law for a doctor to date a patient was absolutely right, mostly, so I’d say you are staring down a very ominous barrel of serious issues. But there is a lot of variation between counseling organizations as to how many years have to lapse before a relationship can be entered in, if ever.

Since Dr. Williams is a psychiatrist, his code of ethics would fall under the American Psychiatric Association (APA), which I knew little about. However, upon a Google search, I came to understand the APA essentially uses the ethical codes of the American Medical Association (AMA). Since a psychiatrist IS a medical doctor, this makes sense. The APA does have an annotated version of the ethical code of the AMA that specifically applies to psychiatrists, yet I couldn’t find anything in this code about sex with a patient (only sex between a faculty member/student and a trainer/supervisee).

So then I reverted back to the AMA’s website. In Opinion 8:14, found here, it reads “At a minimum, a physician’s ethical duties include terminating the physician-patient relationship before initiating a dating, romantic, or sexual relationship with a patient.” It sounds like Dr. Will

iams does this, at any rate. But honestly, this sounds like its more for general practitioners or surgeons or something, not psychiatrist doctors seeing patients in a therapeutic relationship. Let's face it, that's way different from a doctor doing a knee replacement or something.

As a therapist, this “opinion” makes me cringe. I hold to the code of ethics of the American Association of Marriage and Family Therapists (and additionally to the American Association of Christian Counselors). Our code read much more substantially:

1.5 Sexual intimacy with former clients is likely to be harmful and is therefore prohibited for two years following the termination of therapy or last professional contact. In an effort to avoid exploiting the trust and dependency of clients, marriage and family therapists should not engage in sexual intimacy with former clients after the two years following termination or last professional contact. Should therapists engage in sexual intimacy with former clients following two years after termination or last professional contact, the burden shifts to the therapist to demonstrate that there has been no exploitation or injury to the former client or to the client’s immediate family.

See the difference? Of course, what’s really on the table are sexual relationships, which Dr. Williams will not be having with Molly at any rate. But dating relationships still fall under a gray area…because in most of the world, that leads to sexual relationships (in or out of the marital covenant).

The other area your book brings to light is what constitutes a patient. Does an evaluation/assessment count? What if the client wants to meet the therapist to determine if she would mesh well with his treatment modalities?

To answer this question, you’re going to have to really think about these four “evaluation” sessions. I’m not sure what all he’s evaluating that would take that long. It sounds like some of the assessment sessions might be more. Typically, for therapists to get paid by insurance parties, you have to have the assessment done and at least a temporary initial diagnosis to submit to the insurance company. You can continue to “evaluate” if you feel another session might be needed to really nail the diagnosis, but most good therapists/psychologists/psychiatrists already have a very good idea after one hour, I promise.

So what’s really going on in those sessions? How much evaluation does she really need? And what’s taking him so long? I guess what I’m trying to say is that four sessions would likely constitute a therapeutic relationship of some sort. One could assume a session happened every consecutive week and that they were going deeper and deeper into her personal history, problems and reason for coming in the first place. If I were reading your book and read that they’d had four sessions, I would think he was being unethical, then, when he enters into a dating relationship with her. This would put me off so much I might be tempted to close the book, but I’m not the average reader in this area.

You’re doing what you need to do, though, by researching. You want your book to fall into the feasible plot realm for a psychiatrist, and from what I see, you have Dr. Williams dangerously skirting around the line of unethical behavior. Technically, according to the AMA, if he ends the medical relationship, he’s cleared to date her. Morally, though, this might not sit right with a lot of the population of readers. They will resonate with Molly’s sister and best friend, which you’re not going to want!

So now that I’ve possibly ruined your plot premise with my assessment, I’d like to maybe give some alternatives. If possible, decrease the number of sessions they actually have. It will be far more ethical for him to have one session—two, tops—and then not take her on as a patient and date her. I realize your plot twist of him revealing to her he never took her on as a patient is major to the end of the book. Is there anyway for that to come out earlier? Like before they actually go on a date? Then the reader’s mind would be at rest for the remainder of your story. Maybe there would be some other great reveal at the end...like why Dr. Williams isn't with his ex or something.

Another option is for Dr. Williams to perhaps be in a practice where there are more than just one psychiatrist working. Perhaps Molly could be seen by one of Dr. William’s associates and therefore totally bring their romance out of the sticky realm of one of his own patients.

I’m not sure this helps much. I feel like this is the first assessment I’ve done that wasn’t all that positive! Please feel free to email me if you have some other questions, or just leave them in the comment section. Good luck with your writing! Other than the ethical dilemma, it sounds like a superb romantic comedy!

This service is for fictional characters only, so any resemblance to real life examples is entirely coincidental. Any other fictional character assessment questions can be directed to charactertherapist@hotmail.com.