Secrets: How and when patients should reveal

"We’re as sick as our secrets.” It's a commonly held belief. Whether it’s Catholics in the confessional, 12-Step recovery participants doing their 5th Step, or individuals participating in talk therapy, acknowledging past unhealthy behaviors and expressing a desire to improve has great therapeutic value.

There is a caveat, however: Not every secret needs to be revealed. The secrets we’re talking about here are the ones that lead to guilt and shame—the ones that should be shared.

At many recovery meetings, the chairperson (or the entire group) will say something like: “Who you see here, what you hear here, when you leave here, let it stay here.” The group usually responds: “Hear hear.” This serves as a good reminder of the importance of anonymity, confidentiality and trust.

Unfortunately, people talk. People gossip. There is nothing to stop the flow of rumors, misinterpretations and outright lies that might emanate from recovery meetings.

So what is the correct “hierarchy of sharing”? How will patients learn what to share, when to share and with whom to share? Addiction professionals find themselves in a unique position to provide guidance on these sometimes perplexing issues.

In a public forum

A public forum could include any “self-help” gathering, from a church group, health club or recovery meeting to an informal gathering of like-minded individuals. Although the group may claim to be respectful of secrets, there is no guarantee, because no one in the group is legally obligated to maintain confidentiality. (Ironically, many experts believe gossip serves as an important part of our evolution, useful in forming healthy peer groups.)

Professionals' advice to clients should be this: Talk in generalities in these settings. Avoid anything you wouldn’t want people to read in the local newspaper, including criminal behavior, sexual practices and family secrets. Avoid discussing details of past trauma, even though it might be tempting to do so. This could retraumatize the client, or others in the group.

Finally, resist the temptation to “perform,” to tell hilarious stories that entertain the crowd but contain too much personal information. Individuals in early recovery commonly make this mistake.

With a trusted adviser

Here, there’s some gray area, because every relationship is different. As Anton Chekhov said, “You must trust and believe in people, or life becomes impossible.” Ernest Hemingway said, “The best way to find out if you can trust somebody is to trust them.” A bit more cynical, Ronald Reagan said, “Trust, but verify.”

The bottom line is it’s never completely obvious whom we should trust and with what information. Our patients might need our help in navigating these waters. A group facilitator, a 12-Step sponsor or a long-term close friend might very well be trustworthy resources. But they are not contractually obligated to observe one’s confidence. They are human and often lack training in maintaining appropriate boundaries. So the “Who do I trust?” decisions will ultimately rest with the individual.

With a licensed confidant

This is the category where one can realistically assume that privacy will be assured. However, even therapists violate their code of conduct, though this occurs rarely. If they do share someone’s secrets, they risk losing their license to practice. This is equally true of ministers, psychiatrists, doctors and lawyers. Other providers of professional services (teachers, yoga instructors, probation officers, spiritual advisers, massage therapists, physical therapists, etc.) also might be placing their licenses at risk by violating boundaries. Patients should discuss confidentiality issues in order to better understand the protection and limits provided by professionals involved in their care.

Of course, there are exceptions. Most professionals are “mandated reporters” who must advise authorities if a patient is suicidal, homicidal, reporting child abuse or elder abuse, or intending to harm someone. But beyond those exceptions, one can reasonably assume one's information will not be shared with anyone.

Insurance reports, by the way, can be a slippery area for our patients. The information, often in progress notes provided by the therapist and available to the insurance company, is generally wrapped in non-specific language. The most intimate details usually are not specifically addressed. This is considered protected health information and held in the highest confidence. While all health records are protected under the Health Insurance Portability and Accountability Act (HIPAA), mental health records are held to an even higher standard of secrecy. This should ease patients’ anxiety about talking freely to a trained professional.

It is important for people in recovery to unload, to share secrets with another person. But a hierarchy of sharing exists, and we can help patients avoid embarrassing mistakes by stressing that there are some things that they can say in a group, but others that they should save for a sponsor or trusted friend/adviser. And then there are things they shouldn't even tell their sponsor. They should save those highly personal stories for their licensed therapist, minister, doctor, psychiatrist, etc.—people who are trained “secret keepers” and whose license status hinges on their ability to do so.

Brian Duffy, LMHC, LADC-I, is a mental health counselor at SMOC Behavioral Healthcare in Framingham, Mass. His e-mail address is bduffy@smoc.org.