Secrecy in Mental Health

It feels like a good day to call out an issue I see in my field, which has improved over the years but still persists.

In my line of work, there is a long history of secrecy around clients’ charts and documentation. I don’t mean keeping clients’ information confidential from third parties, which is both an ethical and legal obligation, but a tendency to keep client information secret from the client. I remember a professor in my graduate program saying that, if a client has certain diagnoses, the therapist should not disclose it to them.

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Photo by Anna Shvets on (When your stock photo options include a dog, always choose the dog)

Imagine if your medical doctor declined to tell you that you had diabetes. This would be considered wildly unacceptable. And yet it is appropriate if the client’s diagnosis is related to their mental health? And some of my colleagues wonder why clients might struggle to trust their therapist.

Fortunately, what is considered best practice seems to have shifted. Recently in a therapist Facebook group (I know, I know), a therapist anonymously asked if group members would treat a client without disclosing the diagnosis. I commented, “Informed consent includes the client understanding *what* we are treating and how.” If I recall correctly, no one yelled at me for that comment. (If you know therapist Facebook groups, you will know how rare that is.)

At the same time, there is still debate and hesitancy around giving clients access to their full records (progress notes, psychological evaluations, et cetera).

One argument is that you do not know how a client will handle seeing what is written, and it might harm them. I wonder why someone would write harmful things about the client in their own chart. Yes, a client could misinterpret something I wrote in a way that is harmful, but that is why I always review records with them before releasing them. I also make sure every client I see understands that they can come to me with questions, concerns, or misunderstandings.

Another argument I have heard is that we cannot guarantee what a client will do with their record. They could leave it unattended, and someone else could see it. They could post it on the internet! I again wonder why this logic only applies to mental health records. My primary doctor has always given me a copy of my test results – in fact, I can sign onto my EHR right now and see everything she wrote about me at our last appointment. If I choose to leave my portal logged in and unattended, that is on me. If I share my test results online, that is again on me. What I do with my records is on me, not the provider.

Now, I can think of one circumstance where I would be concerned about a client keeping a copy of their own records: when I worked in a shelter for women leaving domestic violence, sometimes our residents would return to their abuser. (Leaving an abuser is complicated and difficult, so if you say anything about “why would she go back,” I will throw something at you.) If she asked for a copy of records to keep in the house with the abuser, I might say, “You can review your records here, but I am worried that your partner could see a copy in your home and harm you as a result of what he saw.”

Outside of this very specific safety concern, though, an adult has the right to their medical records. What if they want to review and make sure they remembered their diagnosis correctly? What if they want to bring the report to another healthcare provider and not have to wait for me to fax it over? What if they are moving and find it easier to bring records with them instead of requesting they be forwarded?

We need to move away from infantilizing adult clients to empowering them to make their own choices about their records. Mental health care is not us-versus-them, it is us collaborating with them to have their best life, which includes access to their own records.

Published by Dr Marschall

Dr. Amy Marschall received her Psy.D. from the University of Hartford in September 2015. She completed her internship at the National Psychology Training Consortium with specializations in assessment and rural mental health. Currently, she specializes in trauma-informed and neurodiversity-affirming care, and she is certified in telemental health. Dr. Marschall runs a private practice, RMH Therapy, where she provides individual and family therapy as well as psychological assessments across the lifespan. Dr. Amy Marschall is an author and professional speaker.

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