Therapy for people in prominent positions: confidentiality when people know who you are

The car has been sitting in the car park for ten minutes. The engine is off, the phone is in hand, but the eyes aren’t on the screen — they are on the rear-view mirror. Who just came out of the building? Do I know them? Will anyone recognise me when I walk through the door? What if I’m seen by someone who watched me in a meeting yesterday, or read about me in the paper, or saw me on television?

For many people the decision to start therapy is hard enough on its own. For those whom people know — because of their position, their office, their public appearances or simply because in a smaller town everyone knows who is who — there is one more obstacle before the first step: the fear that someone will find out. That fear is understandable, and it shouldn’t be brushed aside with soothing phrases. It deserves precise answers.

In this post I will explain what confidentiality in psychotherapy means, who learns what, where its limits lie and how things are usually handled when a therapist and client meet outside the therapy room. I will write in general terms — about how confidentiality is regulated in the profession — because every therapist is responsible for explaining to you how they themselves work.

The fear of exposure doesn’t stay at the door

The fear that someone will find out doesn’t end when you sit down in the therapy room. Often it simply moves. Barry Farber, who spent many years researching what people do and don’t tell in therapy, published a study with Matthew Blanchard in 2016 in which 93 per cent of the clients surveyed said they had lied to their therapist at least once. Most often not about big things, but about how bad they really felt — they made their distress seem smaller than it was. The most common reason was shame and fear of how the therapist would see them.

This is an important finding for anyone worried about confidentiality. It shows that trust isn’t something you receive at the door, but something that grows. And that it is entirely normal not to say everything at the beginning. For people whom others know, this caution is often even greater, because they have learned that every word spoken can have consequences. In meetings, in the media, on social media. Why would therapy be any different?

The answer is: because therapy is the one space built precisely around the idea that what is said stays where it was said.

What confidentiality really means

Confidentiality is one of the founding principles of psychotherapy. It is set out in the ethical codes of professional associations, in data protection law and, in Slovenia, recently also in a dedicated act, which I wrote about in Slovenia’s new Act on Psychotherapeutic Activity. Under the General Data Protection Regulation, data about mental health belongs to the special categories of personal data, which enjoy stricter protection.

Confidentiality doesn’t cover only what you say. It also covers the fact that you are in therapy at all. Without your permission, a therapist won’t tell anyone that they are in contact with you — not your partner, not your employer, not a journalist who happens to ask. If someone calls and asks whether you see a particular therapist, the therapist won’t confirm it.

You will find a short explanation of the concept in the knowledge base under Confidentiality, and I wrote about it in more detail in Confidentiality in therapy: what stays between us and where the limits are. Here I would like to stress something that matters especially for people in prominent positions: confidentiality isn’t a courtesy or the goodwill of an individual therapist. It is a professional duty, and breaching it has consequences.

Who learns what — and what no one learns

When people think about confidentiality, they often imagine it as all or nothing: either it is completely sealed or it isn’t safe. In reality, confidentiality has a few clearly defined layers.

The first layer is everything that happens in the room. Your words, your name, the notes the therapist keeps and the fact that you come. No one learns any of this without your explicit permission.

The second layer is supervision. Therapists talk about their work with more experienced colleagues. This isn’t an exception to confidentiality but one of the ways the quality of the work is ensured. For therapists in training, like me, supervision is a mandatory part of training. In supervision, cases are discussed without any details by which you could be identified, and the supervisor is bound by the same duty of confidentiality. More under Supervision and in Where therapists take their feelings.

The third layer is the exceptions. They are rare and clearly defined. They cover situations where a life is in danger — yours or someone else’s — or where a child is at risk. In those cases the therapist’s duty to protect life outweighs the duty to keep silent. And when disclosure is required by law, for example by a court. Even then, only as much is disclosed as is strictly necessary.

Why the fear is greater when people know you

If confidentiality is so clearly regulated, why is the fear so strong? Because it isn’t fear of the rules. It is fear of consequences that rules can’t entirely prevent.

In 2015 Sarah Clement and her colleagues reviewed more than a hundred studies on how the stigma of mental health problems affects help-seeking. They found that stigma deters people from seeking help and that, among stigma-related barriers, the most common was precisely concern about disclosure — the fear that others would find out. Patrick Corrigan, one of the leading researchers on stigma, described how people avoid help not only because of what others might think, but also because seeking it would mean seeing themselves as someone who “has problems”.

For people in prominent positions, both are amplified. Reputation is part of their job. The trust of voters, shareholders, patients, colleagues or the public also depends on an image of steadiness. Many believe — often not without reason — that information about therapy could be used against them.

Slovenia, on top of that, is small. People know one another through work, school, family and friends. The chance that someone will recognise you in a waiting room or a corridor is real, and no confidentiality can guarantee that no one will ever see you. What it can guarantee is that what happens in the room stays there.

Beneath the fear of exposure there is often something deeper. People who are used to being strong for others are afraid not only of what others might say, but also of what they themselves might see inside. I wrote about this quiet but persistent emotion in Shame: the emotion that whispers “There is something wrong with me”. And about why it is so hard to confide in anyone at the top in Lonely at the top.

What it sounds like in a first session

The fear of exposure often shows itself in the very first minutes of therapy, while the person is still checking whether it is safe here. For example, like this (composed, not a real person):

“Before we start — who else will know I’ve been here?”
“No one, unless you tell them. I can explain exactly what stays between us and where the exceptions are.”
“Please. And one more thing… what if we run into each other at the supermarket?”
“Good question. We can agree on that today.”
“You see, that’s why I didn’t come sooner. Because I imagined I’d have to be on my guard the whole time.”
“Perhaps for the first few sessions it really will be like that. That’s all right. Trust isn’t something you have to bring with you.”

Questions about confidentiality aren’t mistrust or rudeness. They are a sign that you take yourself seriously. A good therapist won’t take them personally — they will take them as part of the work. I wrote about what else to expect at the start in What a first session with a psychotherapist is like — no mysteries.

When you meet outside the room

In a small place you may well run into your therapist at the shops, at a concert, at a children’s party or at a business event. For many people this is one of their biggest worries. The profession has established ways of handling it.

The most common rule is simple: the therapist doesn’t greet you first. If you greet them, they will return the greeting; otherwise they won’t approach you. That way the decision about whether anyone with you learns that you know each other stays with you. Talking about the content of therapy at such a meeting isn’t appropriate — if the encounter stirred something in you, you bring it to your next session.

The question of dual relationships matters even more. If you already have some other relationship with a therapist — if she is your neighbour, your partner’s colleague, the mother of your child’s classmate, or you are connected through business — this can be an obstacle. Not because the therapist would deliberately give anything away, but because the two relationships intertwine and one starts to affect the other. In an influential 1993 paper, Thomas Gutheil and Glen Gabbard distinguished between boundary crossings, which can be harmless or even helpful, and boundary violations, which harm the client. Ofer Zur later described how in small communities some overlaps are unavoidable — what matters is that they are talked about openly. More under Dual relationship.

If you know you might meet your therapist in other roles, tell them at the start. Together you will judge whether they are right for you or whether it would be better to look for someone else. I wrote about what else to weigh up when choosing in How to choose a therapist who is right for you.

Exercise: from fear to questions

The fear of exposure is often a fog — large, but without outline. This exercise helps you spread it out and turn it into questions you can get answers to.

1. Write down the worst-case scenario. Without censoring: what would happen if someone found out you were in therapy? Who would find out? What would they think? What would they do?
2. Separate what you fear. Are you afraid someone would find out that you go, or what you talk about there? Are you afraid of consequences for your work, for your relationships, or for how you would see yourself? These are different fears and they have different answers.
3. Check what is in your power. For each fear, write down what you could do to protect yourself. For example: choose a therapist with whom you have no mutual acquaintances; ask how notes are kept; tell no one until you are ready.
4. Draw up a list of questions. From all this, make three to five questions for the first session. For example: “Who has access to your notes?”, “What if we meet in public?”, “In which cases would you have to break confidentiality?”
5. Notice the response. When you ask the questions, pay attention to how the therapist answers. Are they clear, calm and open? That, too, tells you whether this is a space where you can trust.

The exercise won’t remove the fear. But it does make it manageable. Instead of fog, you have a few concrete questions in front of you — and each of them has an answer.

What confidentiality can’t promise

It would be dishonest to present confidentiality as complete protection from everything. It isn’t.

It can’t stop someone from seeing you. In a corridor, in a waiting room, in the street. What it can guarantee is that the therapist won’t give you away and that the content stays in the room.

It doesn’t apply to what you say yourself. If you mention to a friend that you are in therapy, that is your decision and your information. Many people are surprised to find that the reaction around them isn’t what they feared — but that is your call, and no one may push you into disclosing it.

It has exceptions. When a life is in danger, confidentiality gives way to protection. That isn’t betrayal; it is care. If you are thinking about harming yourself and the fear of exposure is holding you back from seeking help: in Slovenia, the crisis line Klic v duševni stiski is available on 01 520 99 00 (every day from 7 pm to 7 am), and the Samarijan helpline on 116 123 (24 hours a day); you can call both anonymously. In an emergency, call 112.

It isn’t proof that the therapist is the right one. Respecting confidentiality is a precondition, not a guarantee of quality. If you feel a therapist isn’t respecting boundaries — talking about other clients, wanting a relationship with you outside therapy or in some way exploiting your position — that is a serious warning sign. I wrote about this in What a therapist must not do.

And finally: the fear of exposure isn’t necessarily only a fear of other people. Sometimes it is also a way of putting off something that frightens us for other reasons. That is all right too. That, too, is something you can talk about in therapy.

What to remember

• Confidentiality also covers the fact that you are in therapy, not only what you say there. Without your permission, a therapist won’t confirm it to anyone.
• Supervision isn’t an exception to confidentiality: cases are discussed without any details by which you could be identified.
• The exceptions are rare and clearly defined — a life in danger, a child at risk, a legal requirement.
• At a chance meeting, the usual rule is that the therapist doesn’t greet you first. Talk about this, and about any possible dual relationships, at the start.
• Questions about confidentiality aren’t mistrust. They are the first step towards trust being possible at all.