Confidentiality I am a therapist working in a clinic. I have a client who has been in therapy for many years for depression. Since he/she has come to our services, we have also diagnosed him/her as paranoid. The latter diagnosis is based upon his/her intense need for confidentiality in the record. In treatment with a previous clinician, the clinician agreed to record only the date, time and diagnosis; no details about the session. The clinician told the client that they would keep separate personal notes. As a therapist, I feel that I am required to write a description of the client’s issues and what we discussed in each session. The client has to read the file; it’s a matter of trust. He/She wants to know how much detail I am writing. The client has expressed feeling hurt that he/she is unable to freely express his/her problems. The client was transferred to me by a therapist in training who wrote great detail in the file and in personal notes about the client. The client feels that the information is too revealing and wishes to have certain detail removed from the file. I see that he/she is in pain over not being able to trust me because I must write about his/her issues. The client is also beginning to anguish over boundary issues. The client was ostracized by his/her community because a leader was attracted to him/her. He/She turned the situation around so that after refusing the advances, word would not get out about them. The community then betrayed previous confidences exchanged over many years. At this point, the client has not had any close friendships for many years. Now, for the first time he/she is connecting emotionally with the therapist, with anyone. Realizing that I cannot return any affection, the client is beginning to pull away from discussing issues with me because of heartache; not wanting to feel emotional pain of unrequited love. Therefore the client is pulling away for two conflicting reasons, but does not want to leave therapy nor do I think it would be advisable. For many reasons not explained here, I can state that the client is not willing re-enter therapy with anyone else; however, I do not feel that we are at that point. The client still wants to try to work out the issues. He/She doesn’t know how to set the limits and finds setting limits painful. The client would prefer that I not keep a record. there is no problem being honest and open issues in person. He/She does not want someone unknown to be able to learn about him/her from reading the file. In my state the law allows files to be subpoenaed for numerous reasons. State law outweighs HIPPA regulations which are still not rigid for the protection of psychotherapy records. Questions: Has anyone encountered a client this concerned about confidentiality/ privacy that the client feels unable to freely express thoughts openly with the therapist for fear of what the therapist will record? If so, what is your advise? Have you experienced a client who pulls away from the intimacy of therapy for fear of being emotionally hurt, perhaps from having a crush on the therapist or just appreciating that for a change someone seemed to care for him/her? The client not wanting to fully engage and express feelings...not wanting to suffer the ultimate pain and loss of caring for a person who cannot equally care back. What are your thoughts and suggestions about the privacy and intimacy issues? I appreciate your insight and sharing your experiences.
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