Musings on Confidentiality in therapy

When it comes to therapy and counselling, what does confidentiality mean?

I was recently contacted by a company who provide private support to individuals on the Autistic Spectrum. I was initially very interested – I’ve worked with people on the spectrum before, and I enjoy working with neurodiverse people.

However, during my initial conversation with the company, it turned out that they expected me to give them, and the family member of the client who was intending to pay for therapy, updates about the client’s ‘progress’ and the content of the sessions.

I have to admit I was very surprised and followed up rapidly with a bunch of questions to work out what exactly was going on. In the end it was pretty innocent – the person I was speaking to just didn’t know very much about therapy. They were working from a medicalised paradigm where it seemed very normal and natural that everyone involved in caring for someone would be sharing information, and from a business perspective they wanted the customer to be satisfied the ‘treatment’ was ‘working’.

I made it very clear that, no matter who was actually paying for the session, the work between me and the client was private and confidential. I tried to be clear but gentle  – as much as I was interested in working with the client, I realised in that moment that confidentiality was a very hard boundary for me and I was in danger of over-reacting in the face of even an innocent challenge!

But what does confidentiality really mean, in the context of therapy?

On a day-to-day basis, it means that everything someone tells me stays with me. You can be sure that when you tell your therapist your deepest fears, most painful moments, things that you are most ashamed of, they aren’t gossiping about them down the pub.

There are limitations. I may have told the company rep that my work with the client would be confidential and private, but there are things that I am legally required to disclose to an authority. What these are varies by country, but in the UK it includes things like serious drug trafficking, terrorism, child safeguarding risks. There are also things that I am going to want to disclose, such as a serious and credible threat to someone else’s safety. Then there are things that I negotiate with a client about, such as what to do if they feel that they want to end their life. Who will we talk to, how will we do that, and what does the client want to happen?

It’s an ethical requirement of the professional register I belong to – the BACP – that I have a supervisor for all my clinical work, and I’d expect any good therapist to have one. When it comes to confidentiality, it’s my supervisor who helps me work out how and when to break confidentiality. One of the main roles of a supervisor is to make sure that the therapists that work with them are working in an effective, ethical way. That means therapists talk about their clients and their clients’ material with their supervisors, but always in a respectful manner, designed to make sure clients are protected, and critically they talk about clients in order to make sure that the client is getting the best therapy from that therapist that they can.

What is the point of confidentiality then, if it’s not actually absolute?

The discussion with the company reminded me that I’m passionate about confidentiality. It’s one of the things that counselling has to offer that makes it different to other services. To be able to walk into a room, to sit down with another person, and know that the things you are talking about are private and safe… for me that offers something powerful and important. It’s about power and trust, in the end.

As a therapist confidentiality is a promise not to interfere with the agency of a client. It’s an act of faith in the client, and a powerful rejection of outside authority and judgement. It’s saying I am not judging you and your actions, and I believe you have the right to make your own decisions. The power is in the client’s hands, not in the therapist’s or in some external authority.

It’s also about trust, the therapist’s trust in the client, and the privileging of the client’s power and agency. Confidentiality contributes to creating a space in which trust can grow, where a client can feel safe talking about themselves, their lives and what’s happened to them. Confidentiality helps to grow that safe space in which the client is free to talk about anything, knowing that it will be kept private. For me, confidentiality is also an act of valuing – I hold what clients tell me, no matter how toxic or awful it feels, and I value the client and try to give them safety, privacy and respect.

Confidentiality isn’t an absolute – neither society nor our own personal ethics allow therapists to offer complete confidentiality. But it remains a powerful and, for me, critical part of the healing potential of therapy, and one of the things that makes what we offer as therapists unique.