Psychiatrists and other mental health professionals often get asked if they keep secrets shared with them during therapy sessions. There are complex ethical and legal issues surrounding confidentiality in psychiatry that impact how much a psychiatrist can and should reveal about their patients. While the default is to maintain confidentiality, there are some exceptions laid out in policies and laws. Understanding what information is protected and what isn’t can help patients feel safe being open and honest during psychotherapy.
What is legally protected in psychiatry?
In the United States, conversations between psychiatrists and patients are considered protected health information under the HIPAA Privacy Rule. This federal law sets standards for protecting medical records and other personal health details. Unless allowed by the Privacy Rule, psychiatrists may not reveal psychotherapy notes or any other information that could identify a patient. There are only a few exceptions that require or allow psychiatrists to break confidentiality:
| Exception | Description |
|---|---|
| Duty to warn | If a patient communicates a serious threat of harm against an identifiable person, the psychiatrist may have to warn the intended victim and notify law enforcement. However, the psychiatrist should only share information needed to prevent harm and comply with duty to warn laws. |
| Court orders and subpoenas | Judges can order the release of patient communications and records for lawsuits and other legal proceedings. Psychiatrists are obligated to comply with these court orders. |
| State mandatory reporting laws | All states require psychiatrists to report suspected child abuse. Many also mandate reporting in cases of elder abuse or abuse of people with disabilities. Details are only shared with appropriate authorities. |
| Serious threat to public health | State laws may compel psychiatrists to report patients who pose a communicable disease risk to others. |
With the exceptions of mandated reporting and court orders, psychiatrists have discretion over what details to reveal. They will aim to protect patient privacy as much as these situations allow.
Key takeaways on protected communications
- Conversations between psychiatrists and patients are confidential under HIPAA.
- Mandatory reporting laws sometimes require psychiatrists to breach confidentiality.
- Psychiatrists may have to warn potential victims identified by threats.
- Judges can order psychiatrists to release patient information.
- Disclosures are limited to only what is required by law and ethics policies.
These protections on mental health communications facilitate open and honest psychotherapy sessions. Patients can feel safe sharing deep personal details without fear of exposure.
When can psychiatrists talk to family and others?
While communications with patients remain mostly confidential, can psychiatrists talk to family members or friends about a patient’s mental health? In most cases, no. Psychiatrists need explicit permission to release information to anyone outside the treatment team. HIPAA gives patients control over who can access their protected health details.
There are two main ways that psychiatrists can communicate with a patient’s loved ones:
With patient consent
Psychiatrists can share information with family, friends, and other providers when the patient gives written authorization. These release forms permit two-way communication within the limits set by the patient. For example, a patient may allow their psychiatrist to discuss diagnosis and medication with their primary care doctor but not personal issues from therapy sessions.
As needed for treatment, payment, and healthcare operations
Without written authorization, psychiatrists can only disclose information to aid treatment, payment, and office operations. For example, scheduling appointments with a family member or submitting diagnosis codes for insurance reimbursement. Even within these constraints, they cannot reveal psychotherapy notes.
Key takeaways on talking to others
- Psychiatrists need patient consent to talk to family and friends about mental health.
- Patients use release forms to allow sharing information with specified individuals.
- Limited details can be shared for treatment, payment, and practice management needs.
- Psychotherapy notes remain confidential unless authorized through a release form.
While communication with loved ones can improve coordination of care, patient privacy remains the priority.
When is it acceptable to break confidentiality?
Psychiatrists take confidentiality extremely seriously, but they are obligated to break it in certain situations:
Risk of imminent harm
As mentioned regarding duty to warn laws, psychiatrists may have to breach confidentiality if they believe a patient poses an imminent, serious risk of harm to themselves or others. For example, if a patient communicates a plan to commit suicide or violently attack someone, the psychiatrist may need to hospitalize them involuntarily for safety.
Grave disability
When a psychiatric disorder severely impairs a patient’s ability to meet basic needs for food, shelter, or personal safety, a psychiatrist may initiate a court-ordered treatment plan. This involves limited disclosures to arrange suitable housing and supervision.
Court-ordered evaluations
Judges can order psychiatrists to evaluate individuals and share professional opinions on topics like competency to stand trial, sanity at the time an offense was committed, or matters relating to child custody. The psychiatrist must comply.
Key takeaways on when confidentiality is broken
- Psychiatrists may hospitalize patients who are an imminent risk to themselves or others.
- If a psychiatric disorder completely disables self-care, court-ordered treatment can be pursued.
- Judges can order psychiatrists to evaluate individuals and testify on limited topics.
- Only information essential for safety and compliance with the law is revealed.
While rarely done, breaching confidentiality can be necessary in extreme cases. But psychiatrists always aim to protect privacy and regain patient trust when this occurs.
Do psychiatrists gossip about their patients?
What about idle gossip about patient lives and problems? Do psychiatrists ever engage in this unprofessional breach of trust?
The code of ethics of the American Psychiatric Association strictly prohibits psychiatrists from revealing any identifiable information about patients for personal gain, curiosity, or casual sharing. Psychiatrists understand that maintaining confidences is foundational to psychotherapy. Patients will not open up if they fear their deepest secrets could become gossip material.
Gossiping, exaggerating, or lying about clinical work clearly violates principles of integrity and respect for patients. It reflects poor judgment and lack of professionalism. Engaging in these harmful behaviors can result in disciplinary action by state licensing boards. Professionals who cannot maintain patient privacy and dignity have no business practicing psychiatry.
Key takeaways on gossip
- Psychiatrists cannot ethically reveal identifiable patient details for gossip.
- Idle sharing of confidential information reflects poorly on professionalism.
- Gossiping undermines the trust essential to psychotherapy.
- License suspension or revocation can result from privacy breaches.
While occasional sharing of non-specific case details with colleagues for training purposes may be acceptable, gossiping about patient lives is never appropriate.
Do psychiatrists have any legal obligations to report crimes in therapy sessions?
Many patients worry that confessing past illegal behaviors or criminal thoughts in therapy could land them in legal trouble. However, psychiatrists generally do not have a duty to report crimes mentioned in session. Two exceptions relate to child abuse and immediate safety risks:
- Child abuse: If past instances of child abuse are confessed, psychiatrists in all states must report this to authorities as required by mandated reporting laws. The priority is protecting vulnerable children from harm.
- Imminent danger: If a patient discloses plans to commit a specific crime that would seriously endanger someone, psychiatrists may have to report this to prevent imminent harm. However, this would only apply to dangerous crimes not yet committed.
For past crimes not subject to mandated reporting laws, psychiatrists are not obligated to report these to legal authorities. However, they may encourage patients to self-report past offenses that could still pose a risk to others if left unaddressed. This upholds public safety while maintaining patient trust.
Key takeaways on crimes mentioned in therapy
- With limited exceptions, psychiatrists keep past crimes mentioned in therapy confidential.
- Harming children and danger to others may require reporting to authorities.
- Self-reporting may be encouraged to prevent future risky behaviors.
- This nuanced approach balances therapy rapport, ethics, and public safety.
Not reporting most past offenses facilitates patients opening up to get help avoiding future harmful behaviors.
Conclusion
Psychiatrists have an ethical and legal duty to protect communications made for mental health treatment. Breaching confidentiality can only be done when truly necessary for safety or compliance with the law. While complexities exist, patients can generally feel their secrets remain secured through proper psychotherapy. This allows for honesty and progress that would otherwise be difficult if everything was openly exposed. With clear policies on confidentiality, psychiatrists can maintain patient trust and demonstrate their firm commitment to upholding privacy.