Over time, good clinicians frequently come to similar conclusions. One of those conclusions is that family involvement in treatment can help the person in therapy find deeper and healthier relationships with important people in their lives. While it is not always possible to “fix what is broken” in family connections, meeting or speaking with a client’s family or other loved ones can help the therapist understand who or what that person is dealing with. Despite the value of family involvement, certain myths prevail concerning HIPAA and contact with people in your client’s support system. Many clinicians falsely believe that without a signed release of information, they are not supposed to listen to or take a call from a family member or outside support. Please note that I said “listen” and not “talk.”
I spent years working with children and adolescents and on psychiatric inpatient units. The person you see in your work with youth and those who are hospitalized is a snapshot of who they are in that moment (which is true for all human interaction). What we can’t see is the “person in their environment.” The information that is not readily available is often at least as important as what the person presents to us.
I have encountered multiple instances in which a family member reached out to a clinician and was told by the treatment provider, “I can’t talk to you because of HIPAA.” A particularly disturbing situation occurred when a grandparent called a therapist to share that their young adult grandchild was in distress. The grandparent wanted to share what the family was seeing, which included increased, inexplicable conflict with the family. The clinician refused to listen to the information, citing HIPAA. The therapist’s refusal to hear the information was particularly disturbing to the family member because the young person had a history of suicidal ideation and appeared to be deteriorating. A therapist might be concerned that even a discussion is disclosing that the person is in their care. In this case, the grandparent was paying the therapy bills. There was no “disclosure” that would have resulted from the therapist listening to what the family member was trying to share. Even in an inpatient hospital setting, without confirming or denying someone is in treatment, a clinician can say, “I am not authorized to disclose any information. Is there something you’d like me to know?”
So, what is a clinician to do? Consider the following:
- At the beginning of treatment, it should be standard practice to explain to clients that their information is confidential. The exceptions to that are in the case of suicidality, homicidality, child abuse issues (if that is relevant), or the need to coordinate emergency care. (These are standard HIPAA parameters).
- Ask the client for a signed HIPAA release for emergency contact. You can also ask if it’s ok to share “psychosocial information” with family if it is deemed appropriate. It is important to note that not all clients would have an issue with family contact. (In the scenario cited above, the young adult actually had a positive relationship with the grandparent. It was the therapist who assumed the contact would be unwanted and a violation.) Your client can also specify limits around what can be disclosed or discussed.
- As with any protected health information, all communication should be done privately (by phone or in person). Any information shared should be handled in the same manner as all other protected health information.
- If a family member contacts the clinician without the client’s knowledge, which is often common with children, it is appropriate to state (if the client has not given a HIPAA release) that you cannot share information due to HIPAA. But you can listen. As a matter of clinical standards (as opposed to HIPAA standards), I would never agree to keep the contact with the family member from the client. I would inform the family that I would need to share with the client that we’ve spoken. No matter the nature of the information, I would not agree to “keep it secret.” It is not clinically useful to have information you can’t discuss with your client, and it is countertherapeutic for a therapist to be talking about a client without their knowledge.
- Paradoxically, I would not necessarily try to discuss all these possible scenarios at the beginning of treatment. The client does not yet know you well enough to trust you and may be feeling vulnerable with their family. You cannot cover every contingency that might emerge around family contact. Discussing this too early might prematurely force the client to say, “No, I don’t want you to have any communication with my family.” Once that is made explicit, that must be respected.
Both as a child and adolescent therapist and an inpatient psychiatric social worker, families have contacted me and wanted me to listen to what they have to say. More often than not, information shared by them was helpful for assessment and treatment planning. Children, in particular, live in the context of their family and school. Not involving these systems may render the therapy less helpful than it could be. The connection to the family and the support system also creates pathways to enhancing community supports.
The important thing to remember is that HIPAA is designed to protect privacy and protected health information. Talking about a client without permission is a HIPAA violation. Listening is not and is often a means to create more effective and robust care.
Acknowledgment: David C. Barry, JD, MSW, LSW, for his review of this article.
Elaine Edelman, PhD, LCSW, CASAC-Adv., is Professor of Practice at Kansas State University.
