The Therapist and Confidentiality

This will be a maximalist post.

1. Confidentiality/other professionals:

Some of us like to consult with other doctors. To do this we must first ask the patient to sign

The Release of Information

which consists of pages of legalese and finally, the

Date: _____________________________
Printed Name:______________________
Signature __________________________

You can tell how professional the professional by the uniformity of the lines.  This is harder than it looks, uniformity in lines.

I always assumed that the form protects the patient from a breach of privacy. If someone other than the doctor handles a faxed evaluation,  

             Release of Information
-- PERSONAL AND CONFIDENTIAL-- 

attached, surely that individual wouldn't think of reading the evaluation.

For sure not.

When Blue Cross/Blue Shield of Illinois audited my charts last summer (they said I did high volume so of course they had to audit my charts) I was told that my default releases of information, sometimes an abbreviated form, sometimes handwritten scribble scrabble, didn't cut it. I learned this before the audit, thankfully, so that when BCBSIL really did have a look, my forms were HIPPA compliant.  No chance of breach of privacy there, an audit of mental health records.

And twenty-plus Office Maxed copies of:

I hearby give Dr. ______ permission to speak with _____________ about anything she wants to talk about regarding me, with the exclusion of _____________________, which she should totally not talk about. This release is good for exactly thirty days, starting

Date: _____________________________
Printed Name:______________________
Signature __________________________

went to recycling.

But in the past, within those thirty days I would track down that primary care doctor or psychiatrist and we would pick one another's brains and come up with a logical assessment and a treatment plan. All assuming the patient concurred that such a discussion might be a good idea.

Then the fun would begin.

If you're a family therapist and you work with family physicians or family psychiatrists, the beauty of consultation is that both of you probably know other people in the identified patient's family system. You both have priceless data to share. What’s wrong with the patient isn’t based solely upon the patient's perspective anymore, but that of generations of souls.

At some point as a professional, you gather a small army of professionals who think like you, work well with you.  And if you’re me, you want to know them better. It's not enough just to talk shop.  But this isn't efficient in professional life, yapping about your own health or family matters, even if the interest is there. There's no time, not even for professional geography, a Who Knows Who.  So we rarely finesse professional intimacy, is the truth.

There are pluses and minuses to privileged consultation, besides all the shared data about the patient, which is surely a plus. And each has something remotely related to intimacy in relationships. Relationship therapists see all relationships through the intimacy lens.  It is an occupational blessing and a hazard, too.  

On the plus side, consultation is essentially chatting, which is always fun.  And it's about a mutual patient. This makes it feel like the two of you are just a couple of friends, chatting it up about someone you both know, relieving tension, because your patients are sometimes a danger to themselves or others, and you want to be sure everybody's safe. That is your job. That's what you're paid to do.

But you hardly ever do this with friends, just chat it up about someone else, certainly not someone who isn't a first degree, because you're a professional and you almost feel like you need a release of information to talk about other friends to your friends, unless there really is a danger and you think maybe that your psycho-education might help.  We're not good gossips. 

So this feels good, talking with other professionals about other people.  We finish talking about the patient, then maybe sneak in a few words about our money stress and how we're going to stop taking credit cards.  Some of us find this intimacy (work intimacy) lacking, a little shallow, but it's better than nothing.

On the minus side, it's not like we speak with our consultants every day, probably not even every week.  If we catch up once a month, even every two months, we are doing extremely well.  So if a physician dies or gets sick (and this happens), crazy as that sounds, we might not hear about it until a mutual patient tells us about it in therapy!

When that happens, I can tell you, we're totally taken back, stunned, and the poor patient's visit becomes a discussion of our mutual loss. And then it turns into an exercise in self-restraint for the therapist, keeping it about the patient.

(One day we'll have to talk about that self-restraint, how we do that, keep it all about you, even after hearing that one of the neighborhood kids has died in a tragic accident or our own kid didn't make it home from school that day. It really is an art.)

Another minus is that if you do finesse the intimacy, you end up making people wait because people are always waiting.  Between two professionals, at least one is going to have somebody in the waiting room, perhaps even on an exam table! So you make your call brief and you feel badly, because despite what people think, everyone wants to run on time.  So as soon as it's getting good, one of us has to go.  You could say we're avoiding intimacy, but we're not.  This is being professional, running on time.

The best thing about consultation, the biggest plus, I think, is that when it's good, it is mutually validating (which all relationships should be, of course). Good consultants don't just want to tell over what they know about the patient. They want to learn something new.  So we listen with respect and we validate the other's thoughts and opinions. We do it for one another.  It's a love fest.

2.  Confidentiality/our families:

When your sister-in-law tells you something about someone, she has no Release of Information, and you don't either.  It's implied that neither of you will tell anyone, and you probably won't.  But sometimes you slip, you have held secrets all day long, and have left your professional hat at the door.  Even therapists, who should know better, can be weak at the end of a long day, when it comes to family secrets.

I know, I know, you're going to say, I am a therapist and I can keep a secret!   I'm the best secret keeper in the universe.  And that may be true.  But not everyone can do it, and kol haKavod to those who can. (Hebrew, rhymes with dole-pa-la-toad, means you're awesome, deserve respect, more power to ya').

My in-town kids and I tried to keep a surprise visit from FD. One of our out-of-town kids was coming in for a wedding, unexpected. Even the bride and groom were sworn to secrecy. She wasn't coming in for three weeks. 

Three weeks of secret-keeping.  This proved to be impossible. We blew it four times, which averages to over once a week, and everyone took turns blowing it.  FD is so clueless, he didn't even notice until the fourth blurt, and maybe he wouldn't have noticed then, maybe we could have mystified him about the blurt, but one of us, ahem, simply couldn't handle it anymore. And she gave it all away.

It could be that the whole gestalt, keeping the lives of everyone else so hush, hush, makes some of us a little loose with our own families. Or our boundaries are bad.  I'll try harder, is all I can say. I really will. People change.

As long as we're talking, please don't take that story as permission to blow family secrets, good or bad, it's really not permission, not at all. The best line ever about this came from the mouth of one of my first degrees. When I asked if I could tell someone else in the family a secret she had just told me, she said:

It's my secret to tell!

Good or bad, secrets are proprietary, and there's joy, and pain, in the telling. It is the owner's right to both.

3.  Confidentiality and friends:

Therapist are used to being tailors.  People take off their clothes, we rip them apart, put them back together again, seamlessly, to the consumer's measurements. We like being tailors, like getting to know what people are made of, and in the end, despite the cutting and sewing, everyone feels better.

Most of the time.

And our friends, depending upon our friends, try to do the same thing with us. To us. Because who doesn't want to rip into a therapist?  It's so much fun, and we're such good sports, and we tell you when you're right, and correct you when you have no idea what you're talking about, with a Nice try! But think about it this way.  And we pontificate psycho-babble until everyone is bored out of their tree.

Sometimes friends want us to help them, too, and we gladly oblige.  Friendship is a two-way street, after all.  It's complicated because of the attachment-detachment conundrum. We're used to detaching with patients, while at the same time being empathetic. The empathy chip is working all the time, in all of our relationships, as a default, sometimes better than others. No matter, an empathetic therapist gets better at detaching from patients over time.

But the empathy chip, let's just digress to that for a sec, is always whirring. Empathy, by definition, implies a sense of caring and genuine concern, which is why you see so many therapists nodding until you want to strangle them. It is the active ingredient in therapy and in friendship, as it turns out, tuning in, sensing, sharing the emotional life of another, feeling the pain.  And the joy.

But as professionals, we really don't want calls after hours from patients, so we gracefully detach, keep it all very professional.  And I think we automatically try to do the same with most of our friends, too.  And they do the same with us, maybe because we all have other things going on, or maybe because too much intimacy smothers some of us.  And like attracts like. 

So it's interesting.  Both professionally and in friendship, empathetic humans get their hands dirty.  As professionals we wash every 45 minutes, but with friends we're not so quick to wash it off, or forget.  We'll text a friend quicker than we will a patient, shoot over an email-- You okay?  (I'm pretty sure HIPPA has no room in the rules for texting or email).

People complain about surgeons, say that they are cold. But really, it’s because their engagement and detachment are so brief, so clean, so surgical that there is no time for more. At least that’s the excuse I’m giving them.

Back to friendship. If I am having a long talk with a friend, at the end of 45 minutes I get a little antsy.  Still, after all these years. When I realized that my friendships were lacking because of this, that it really is a problem for me socially, I suggested we take off for parts unknown (at least a half hour from home, Chicago's a big town) and that we stay overnight. I don't know how we ever pulled that off, seriously, looking back, but it was great and we did it for a couple of years in a row.  Now I understand that bridal parties are doing this, getting out of town for weekends, even weeks, with fairly drunken outcomes.

My guess is that the intimacy is just too much, so people get bombed.  And with that?  Everyone's confidentiality, certainly, goes out the window.


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