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Exceptions to Confidentiality in Therapy: When to Break Confidentiality

Confidentiality is a vital component of a Mental Health Professionals work. Clients come to use to talk about concerns and we ask them to be vulnerable and open with us. Protecting their privacy will enhance your therapeutic rapport which in the end, benefits your client. In this blog, I will review the importance of confidentiality and exceptions to confidentiality in therapy.

What is Confidentiality in Therapy?

The American Psychological Association (APA) has developed the code of ethics that mental health professionals abide by in their clinical practice. One of the most important aspects of the code of ethics for Mental Health Professionals to be knowledgeable about is our responsibility to maintain confidentiality.

The APA defines our responsibility as having “a primary obligation and take reasonable precautions to protect confidential information obtained”. One aspect of this would be making sure that our notes and other forms of documentation are stored safely and inaccessible to individuals who do not have permission to view the documents. The other aspect of our responsibility if keeping what clients share in their sessions and other forms of communication private. While this may seem simple, the idea of therapy confidentiality can be complex, and confusing if you do not take the time to educate yourself.

Therapy confidentiality is a key component of a healthy therapeutic alliance. Having a safe space to talk about concerns, struggles, and successes is a necessary aspect of the counseling relationship. Without this safety, clients may hold back what they share for fear of their information being shared. Maintaining our client’s privacy helps develop trust within the relationship.

With that being said, as a practicing Mental Health Professional, you will undoubtedly encounter a situation that makes you wonder if confidentiality should be broken. This is where you would rely on your knowledge of the code of ethics, and legal advice if you have it. Some of us experience them more than others. As an example, a therapist who works in an addiction treatment program may be more familiar with cases that have court mandated treatment. 

What is Confidential in Therapy?

Any information that a client shares with us in a therapy session or in another form of communication is considered confidential. A client’s interpersonal relationships, medical history, mental health history, substance use, fears, and treatment goals are examples of confidential topics.  Additionally, information that is shared with you from other providers regarding the client is considered protected information as well.

The fact that someone comes to us for mental health treatment is protected information that cannot be shared unless we have permission. This can be relevant if you have a family or friend of a client to talk about their concerns, or if you happen to see your client in public. It may be appropriate for Mental Health Professionals to discuss how clients want to handle seeing each other in public to make sure that both parties are on the same page. 

List of Exceptions to Confidentiality in Therapy

Just as the APA has identified our responsibilities in regards to confidentiality, they have also identified situations where we must break confidentiality. It is important to note that there are differences in our legal obligations regarding mandated reporting in different states at this time, so it is important to be familiar with the laws and regulations for your area. If you are unsure about the exceptions as they would apply to the state you are practicing in, it would be advisable to seek consultation with a legal expert who is familiar with confidentiality concerns for Mental Health Professionals.

Below you will find a  list the exceptions to confidentiality in therapy according to the APA are as follows:

  • The client is a danger to themselves
  • The client has made a specific threat to harm another person
  • The client reports any form of child or elder abuse and neglect
  • The client has come for a court appointed evaluation, or is engaging in court mandated treatment
  • The client has waived confidentiality
  • A court mandate to release information

Other situations where a counselor may share client information would be consulting with a supervisor or colleague regarding the case, or for billing purposes.

What is Duty to Warn?

Duty to warn refers to the presence of a law that requires or allows Mental Health Professionals to speak to the authorities if they have reason to believe that one of their clients may become violent. This came into effect in California in 1985 after the Tarasoff v. Regents of University of California case.

It is important to be aware of the legal status of duty to warn in your state, as not all states have the same requirements. As an example, Maine, Nevada, North Dakota, and North Carolina do not have a duty to warn. While Georgia has their own unique standards, the remainder of the states either have a duty to warn expectation or a permissive duty to warn exception. 

How to Discuss Confidentiality in Your Practice

Confidentiality and the exceptions of it is something that clients should be made aware of in your first session. This could be an intake session or a therapeutic session. Mental Health Professionals should take their time when discussing confidentiality with their clients and allow them to ask questions if necessary. Confidentiality is a topic that can be included in an informed consent that your clients review and sign when they begin engaging in therapy.

The APA has identified necessary aspects of an informed consent for Mental Health professionals to include. An example of this would be using language in the document that the client understands, giving appropriate explanations, gaining assent, considering their preferences and best interest, and the exceptions to confidentiality.

If you are working with a client where you can foresee situations where confidentiality would be broken in the future, it would be appropriate to discuss these situations at length so the client knows what to expect. This could occur in a situation where a client has a court mandated treatment, or is meeting with you to obtain information that they expect to be shared in a court case. 

What to do When You Have to Break Confidentiality

When you suspect that you may need to break confidentiality, it is advisable to seek some form of consultation, whether this is from a supervisor or your legal representative. Additionally, you will want to be mindful that you have been maintaining appropriate documentation supporting your concerns. As an example, if you are concerned about a client’s safety, having session notes documenting the reasons for your concern can support your decision to break confidentiality. In a situation such as this, you would want to be mindful of the information that you are providing to the emergency services. You only need to provide the relevant details to your concern, not necessarily the specifics of their therapy sessions. This would include any verbalized suicidal ideation, plans, access to the means of their plan, and any significant changes in their presentation.  This allows you to fulfill your ethical duty, while protecting their privacy regarding some of what they share with you.

If you are breaking confidentiality for concerns related to child abuse and neglect, it may be advisable to consult with a supervisor or colleague to ensure that your plan is appropriate. From there, you will contact Child Protective Services and make a report. Similar to reporting concerns about a client’s safety, you will want to be mindful about what information you are providing. CPS reports are anonymous, so they will not tell the individuals involved where the information came from. If your concern is for a person over the age of 65, you would want to contact Adult Protective Services and make a report with your concerns. Any contact that you have with an outside party should be clearly documented in the client’s chart.

Whereas if you are breaking confidentiality upon request of the client or another entity, you may have a bit more time to prepare for your actions. If you are working with a client who has court mandated treatment, you will likely have to provide reports to the court regarding the client’s presence in treatment and progress towards treatment goals. The court may have a standardized form that they request you complete. If a client has requested that you provide documentation for a legal case, you can have your own lawyer review your report before you provide it to the client’s lawyer. 

Final Thoughts on Confidentiality

Mental Health Professionals should be informed and educated about the exceptions to confidentiality for their area. This allows you to educate and inform your clients in a way that is specific to them and their circumstances that they may be relevant to their case.

If you find yourself in a situation where you believe you may have to break a client’s confidentiality or are being requested to by a legal entity, your best course of action would be to consult with a lawyer and receive direction about how to proceed. It is important to make sure that you are acting in a manner that respects our code of ethics, and our legal obligations.  

TherapyByPro is an online mental health directory that connects mental health pros with clients in need. If you’re a mental health professional, you can Join our community and add your practice listing here. We have assessments, practice forms, and worksheet templates mental health professionals can use to streamline their practice. View all of our mental health forms, worksheet, and assessments here.

Kayla Loibl, MA, LMHC
Author: Kayla Loibl, MA, LMHC

Kayla is a Mental Health Counselor who earned her degree from Niagara University in Lewiston, New York. She has provided psychotherapy in a residential treatment program and an outpatient addiction treatment facility in New York as well as an inpatient addiction rehab in Ontario, Canada. She has experience working with individuals living with a variety of mental health concerns including depression, anxiety, bipolar disorder, borderline personality disorder, and trauma.

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