I’ve lived and worked for 25 years in my rural community of 23,000, where a clinician faces two realities. First, everyone is connected to everyone, be it through family, work or friendship. Second, there are too many clients and not enough therapists. Handling the boundary and confidentiality issues that arise from treating one or more members of an extended family or friendship circle is an unavoidable challenge. Yet, probably like you, I received little teaching when in training on how to deal with this competently.
When I opened my practice, I tried to protect clients’ privacy through the physical arrangement of entrances/exits. Forget it. “Hey Doc, I saw Jim’s car in your parking lot. Does he see you?” I gave high profile clients (mayor, physician, school principal) the first or last appointment. That didn’t work either.
Most of my clients appreciate my efforts to protect their privacy, but understand the limits of those efforts given the reality of small-town life. The few who don’t are usually obsessive, perfectionistic, or have unrealistic expectations. With these clients, one of two things is possible. Either they explore their issue or terminate treatment.
Expect the Occasional Breach
For years, the fear that I’d slip and compromise my clients’ treatments haunted me. Maintaining constant vigilance was exhausting, and worse, didn’t work. A confidentiality breach proved inevitable. The first time, I didn’t handle it well, much less therapeutically. I was defensive and ashamed. After, I felt helpless as to how to make reparations. These are the responses that follow trying, and failing, to control the uncontrollable.
To regain professional equilibrium, it’s necessary to let that shame (or your variant) go. Otherwise, you’ll be stuck in it, which disconnects you from clients and productive work. I’m not saying to stop being rigorous about maintaining clients’ confidence. Instead, use the energy you’re spending on worrying to rebuild the client’s trust if a breach happens. Doing this successfully requires you to accept the client’s upset and use it—and the breach—as a clinical tool to advance treatment.
Teaming Up with Your Client
In my own practice, I carefully screen my clients’ attitudes about referrals before accepting them. When longtime client Mary asked me if I’d treat her sister, Cindy, I ran her through six questions I call the Consent Checklist. It serves three purposes:
• With each step I learn more about Mary through closely observing her verbal and nonverbal responses
• Each step shows Mary my primary commitment is to her treatment
• With each yes, Mary accepts responsibility to partner constructively with me in the event of a breach.
I tactfully decline the referral at any point Mary becomes uncomfortable or says no.
Here’s how the Checklist looks in action:
1. “Does Cindy want to come in?” If the answer is no (it’s Mary’s idea, not Cindy’s), I tactfully decline.
2. If yes, I ask, “What if I accidentally reveal something to Cindy that you told me about her?”
3. If she’s okay with that, I ask “What if Cindy tells me something about you that you haven’t told me and I bring it up in here?”
4. If that’s okay too, I go on. “If I take on Cindy, I’ll be just as committed to her as I am to you.” If Mary is ambivalent about sharing me, I don’t accept the referral.
5. If she’s okay with that, I ask, “What if you tell me something about Cindy that I decide I have to share with her? I’ll have to tell her you told me. Or vice versa.” If she balks, I don’t take the referral.
6. If she’s okay, I finish with, “Today, you think you’ll be fine with it, but what if you’re not? Are you prepared to deal with the fallout?”
Importantly, I close by asking myself: Am I willing to deal with the potential fallout? I’m more likely to take the risk if Mary is fair-minded, empathic, and works hard. I’m not likely to if she has a rigid, righteous, or obsessive style, issues with female authority figures, or paranoid interpretations of adverse events.
What if I Decline the Referral? In my experience, Mary will do two things if I decline her referral. First, she will pressure me to change my mind with begging, indignation, frustration, or anger (remember the reality of working in a small town reality: too many clients, not enough therapists), or ask something like “What’s Cindy going to do?” and its corollary, “How do I handle her disappointment?”
The first always makes me feel bad but I remind myself that I’m not responsible for the therapist shortage. Over-extending myself only sets me up for mistakes and burnout, neither of which serves clients. Instead, I offer Mary a list of treatment resources however limited, to give Cindy. As for helping Mary deal with Cindy? That’s just the latest iteration of the work in progress.
If I accept the referral, I run the new client, in this case Cindy, through the Checklist on intake. If she refuses consent at any point, I explain (kindly) that’s a deal breaker and refer her out.
I once treated three friends separately in therapy. Nancy, Tilly and Gabby had been friends for almost 40 years, each seeing me for over a decade. They often used their sessions to express worries about each other—a clinical goldmine and confidentiality minefield.
When Nancy said (in passing, assuming I knew) that Gabby had suffered from alcoholism and anorexia in her 20s and 30s, this was news to me. Gabby had lied to me by omission. Nancy continued, saying she feared Gabby had relapsed into addiction, this time with her pain meds. “Sure, tell her I told you,” Nancy said. “If she gets mad at me, I’ve got big shoulders.”
When I brought it up with Gabby, she was evasive about her pain meds and angry at Nancy for blowing her cover. I handled her response to the deliberate disclosure just as I would a slip: I offered to have Gabby and Nancy in for a few joint sessions.
I’ve found my clients usually appreciate this. There’s nothing more gratifying to them than re-bonding around giving me hell. Gabby forgave Nancy and confessed she was relieved I knew her secret, which moved her treatment forward.
If you’re in rural practice, you’re sure to have similar challenges working in the back forty. You may never breach a client’s confidence. But if you do, or have to, don’t forget that the client, through your proactive use of the Checklist, has agreed to work with you to use the breach as an opportunity to advance the treatment. Hard work, true. But at least you’re driving the tractor; it’s not driving you.
Photo © iStock/Tetkoren
Daniela Gitlin, MD, is rural psychiatrist in private practice in upstate New York. Her clinical memoir Practice, Practice, Practice: This Psychiatrist’s Life was selected a Finalist by the 2021 International Book Awards. Her second book, Doorknob Moments: Why Clients Drop Shockers on Their Way Out the Door and Why You Want Them To will be published by WW Norton in 2024. Learn more at danielagitlin.com.