The Secret
Your client Sally, who is also your friend, tells you during a session that she is three months pregnant. She mentions several people in your mutual circle who know her good news and she doesn’t tell you it’s a secret. Soon after, Martha, who is a friend of Sally’s, comes for a session and complains that Sally has seemed preoccupied and unavailable lately. Thinking you’re doing Sally a favor by explaining, you say, “That makes sense. After all, she’s pregnant.”
Later, an outraged Sally calls: “I specifically didn’t want Martha to know that I’m pregnant yet. She is so negative and pessimistic and I wanted to be further along in my pregnancy before I told her. I assumed that what I told you in a session would be private.”
Does she have a right to be so angry? After all, you were only trying to be helpful.
This situation has an easy answer: anything a client says or does in a session is covered by your commitment to confidentiality and cannot be shared without the client’s permission. This commitment extends even to the content of friendly conversations or small talk between you and the client while in your office. (Emergency exceptions are discussed later.) The rule also covers any communication with, or about, the client that is related to your professional association with that client, such as a phone call, e-mail, or fax.
It’s not appropriate for us to make judgment calls about what we can share of a client’s information and what we can’t. For example, a client tells you she’s taking a vacation to Hawaii and you mention it to a mutual friend, not knowing the client owes the friend a good deal of money which she hasn’t paid back. Uh oh!
Even if the mutual friend didn’t have an interest in how the client is spending her money, disclosing anything about a client, no matter how innocuous it seems, is a problem. Not only does it violate confidentiality, but your disclosure could make your friends or clients wonder what else you might be sharing about them and could cast doubt on your trustworthiness. Even if what you disclose is fairly harmless, it’s still not ethical. And it’s a dangerous habit to get into.
These stories also illustrate how much more challenging it can be to maintain professional boundaries and ethical standards when working with friends. Aside from the challenges, when we make a mistake with a friend, we’ve damaged both a client relationship and a friendship.
The Innocent Question
You’ve been going to a couple’s home for a few months, giving a massage to the wife and then the husband. Last week, the husband made a pass at you. You told him you were no longer comfortable working with him, but you would continue to work with his wife. When you return the next week, the husband isn’t around. However, the wife is curious why her husband stopped wanting a massage suddenly. “I don’t understand why he quit,” she comments to you. “He seemed to be enjoying it so much.” What do you say?
You’re going to need both composure and diplomacy here. Maybe the wife is well aware of her husband’s tendencies and will be carefully attending not just to your words, but to your facial expression as well.
Despite the husband’s bad behavior, the rules of confidentiality apply here: you cannot reveal to the wife what happened during the session with the husband. Also, you don’t want to put yourself in the middle of their domestic problems. Even if you say, “That’s a confidential matter,” that might imply there’s a secret she shouldn’t know.
If I were in this situation, I’d want to anticipate that she might ask such a question. I’d want to plan or even rehearse how I might answer beforehand so I don’t freeze in the moment. There’s no set way to respond (and by the way, the massage therapist here could be either male or female), but my reaction would be to shrug and say with a puzzled look, “I couldn’t say” (which is true). And then change the subject as quickly as possible: “Let’s talk about how I can help you this week.”
Although the wife’s question in this case may not be so innocent, another common way we can violate confidentiality is by answering a truly innocent question. Say a client recommends her friend Susan to you and asks at the next session, “How did Susan like her massage?” It’s not a major breach of ethics, but it would still be a breach to say, “Oh, she really liked it.” You’ve just given that person a peek into Susan’s private session. Better to say something like, “I understand why you ask and I know it doesn’t seem like a big deal, but I don’t talk about my clients in any way.” Not only does such a response protect Susan’s privacy, it lets your client know that you honor confidentiality.
The Emergency
An elderly woman has been your client for several months. You’ve noticed lately that she seems more forgetful and confused. Although her daughter brings her to the sessions, you know the client lives alone. You are concerned for her safety; however, you don’t want to ask the client for permission to talk with her daughter for fear it will upset her. The next time the daughter brings her mother in, you speak with her privately while her mother is getting ready for the session and tell her your concerns. Was it ethical for you to do so?
Clearly, you were acting in what you think are the best interests of the client. But putting aside good intentions for the moment, this situation brings up the question of when we can make exceptions to the rules of confidentiality. Circumstances in which we can legally breach confidentiality—and, in fact, are often obligated to—are those in which there is clear and imminent danger to the client or others, there is suspicion of abuse or neglect of a child or incapacitated person, or there is a medical emergency.
The question here is whether the danger to the client is imminent, that is, whether it’s just about to happen. I would think we could make a good case for calling the danger here imminent, as you have noticed that the client’s mental confusion is constantly compromising her safety, raising the fear that she could harm herself at any time.
However, you would be taking a risk. Most likely, the daughter will be grateful for your good intentions. Your observations may be just the reinforcement the daughter needs to take steps to make her mother’s life more secure. However, she could also be annoyed by what she views as butting in. Or she may, on the other hand, begin to see you as the authority in this situation and start to lean on you for advice about how to deal with her mother.
Asking the client for permission to talk with her daughter about your concerns would also be a risk because she could say no. As is often the case with boundaries, the question of talking with the daughter without the mother’s approval could have been avoided by laying the groundwork during the intake process. This dilemma is a good reminder to obtain written permission during every client’s intake process to contact a specific relative or friend in case of emergency. (There should also be written permission to contact relevant physicians, counselors, and so forth.)
Again, calling this situation an emergency may be stretching it a bit, but best to err on the side of the safety of the client. Although there is no specific emergency in this case, the increasing likelihood that one could occur without timely intervention on the mother’s behalf qualifies this situation as one needing action.
Having emergency numbers and names of close relatives can also keep you out of the position of taking on too much responsibility for an elderly or fragile client. Performing such tasks as taking a client to the doctor regularly or acting as a surrogate daughter or son can put you in the precarious position of taking on too much responsibility without legal authority.
None of the specific situations discussed here would be likely to result in ethics charges against you. However, considering the delicate nature of our relationships with our clients, such stories remind us that we need to give careful thought to how best to honor our clients’ privacy and confidentiality.
Nina McIntosh combines more than 20 years of experience as a bodyworker with her previous years as a psychiatric social worker. She is the author of The Educated Heart: Professional Boundaries for Massage Therapists, Bodyworkers, and Movement Teachers (Lippincott Williams & Wilkins, 2005). To learn more about professional boundaries and ethics, visit www.educatedheart.com.
To learn more about illustrator Mari Gayatri Stein, visit www.gypsydogpress.com.