Confidentiality and Therapy: What Are The Limits?

Hello, and thank you for asking this very important question. Limited as you may feel in your ability to provide her with comfort and support, your friend is indeed fortunate to have you in her corner.

It is extremely unfortunate but quite common for individuals who have experienced sexual assault or other forms of criminal victimization to be fearful of coming forward due to concerns about any further trauma which may be triggered by doing so. We can only hope that efforts to reduce the stress of reporting such victimization will persist, and that they will be successful in reducing the cost to those who are ambivalent about telling their stories and seeking justice.

The secondary level of concern that you mention, that of mandated reporting by mental health professionals, is, I am glad to tell you, much more easily allayed. Although I do not know from where in the world you write, I will proceed based on the assumption that your friend resides in the United States (and please feel free to let me know if the facts are otherwise). In the U.S., individual statutory laws and rules vary widely in regard to mandated reporting (and also in what are known as "duty to warn/protect" laws), but the following overall guidelines are typically observed by psychiatrists, psychologists, and other licensed mental health professionals.

Mental health professional are typically permitted and/or required to report to law enforcement or other relevant agencies and parties in some or all of the following circumstances:

1.  When the licensed mental health professional has reasonable cause to believe that suspected child abuse has occurred, or is occurring;

2.  When the licensed mental health professional becomes aware that abuse, neglect and/or exploitation of a disabled adult or elder person has occurred or is occurring;

3.  When the licensed mental health professional becomes aware that a patient under their care is potentially violent and has made a clear threat of harm toward a readily identifiable intended victim; and

4.  When the licensed mental health professional becomes aware that a patient under their care poses a significant and acute risk for self-harm.

Again, these are broad guidelines that are interpreted differently depending on individual state law, but all are observed to some degree by licensed mental health professional. In addition, the definition of what constitutes "abuse," "harm," and "significant risk" are varied and complex. However, these are the only circumstances in which a mental health professional is either compelled or permitted to violate the "doctor-patient" confidentiality attendant to the therapeutic relationship. Thus,disclosure by your friend that she has been the victim of a crime would not, in any case, be the grounds for required reporting by any mental health professional.

I hope that this response is of some use to your friend in reducing her concerns regarding confidentiality and therapy.

Finally, although you did not inquire about the appropriateness of mental health treatment for your friend, in the wake of such a traumatic event, I am going to provide you with the diagnostic criteria for Posttraumatic Stress Disorder (commonly referred to as "PTSD"). This description may assist you friend in better assessing her response to the traumatic event, as well as her need for assistance or treatment:

The diagnostic criteria for Post-Traumatic Stress Disorder are defined in DSM-IV as follows:

1. The person experiences a traumatic event in which both of the following were present:
   1. The person experienced or witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others;
   2. The person's response involved intense fear, helplessness, or horror.
2. The traumatic event is persistently re-experienced in any of the following ways:
   1. Recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions;
   2. Recurrent distressing dreams of the event;
   3. Acting or feeling as if the traumatic event were recurring (eg reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those on wakening or when intoxicated);
   4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event;
   5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
3. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma) as indicated by at least three of:
1. Efforts to avoid thoughts, feelings or conversations associated with the trauma;
2. Efforts to avoid activities, places or people that arouse recollections of this trauma;
3. Inability to recall an important aspect of the trauma;
4. Markedly diminished interest or participation in significant activities;
5. Feeling of detachment or estrangement from others;
6. Restricted range of affect (eg unable to have loving feelings);
7. Sense of a foreshortened future (eg does not expect to have a career, marriage, children or a normal life span).
4. Persistent symptoms of increased arousal (not present before the trauma) as indicated by at least two of the following:
   1. Difficulty falling or staying asleep;
   2. Irritability or outbursts of anger;
   3. Difficulty concentrating;
   4. Hypervigilance;
   5. Exaggerated startle response.
5. The symptoms on Criteria B, C and D last for more than one month.
6. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

Thank you again for posing your question to me, and I hope that at least some of what I have written here has been of use to you in your efforts to support and guide your friend. Please feel free to write again to let me know how your friend reacts to this information, and/or if you have any additional questions.

 

Sincerely,

Richard E. Schultz, Ph.D.

www.drschultz.org