Staff Perspective: Does What Happens in Vegas Have to Stay in Vegas? - Assisting Clients with Decisions About Disclosure

Staff Perspective: Does What Happens in Vegas Have to Stay in Vegas? - Assisting Clients with Decisions About Disclosure

Has one of your Service member or Veteran clients ever said something like this to you?

“I just can’t talk to you about it. I signed that paper saying I would never talk about what we did out there.”

“You don’t understand. People died who shouldn’t have died. If I talk about it, you might have to report me.”

“The things I need to talk about are the things I CAN’T talk about.”

What do we say to our clients who perceive that discussing military experiences is akin to “leaking” classified information or will result in legal consequences?

Recently, I had the opportunity to facilitate a presentation on ethical considerations for working with Service members and Veterans at the Addressing the Psychological Health of Warriors and Their Families one-week workshop in Las Vegas. Yes, I gave a presentation about ethics in Las Vegas. As I prepared for this workshop, the irony of giving a presentation on appropriate conduct for mental health providers in a place that we don’t often associate with the word “appropriate” did not escape me. That isn’t to say that visitors to “Sin City” aren’t expected to abide by an important “ethical” standard: what happens in Vegas, stays in Vegas. 

In all seriousness, the expectation of confidentiality is important when it comes to being able to express oneself in a genuine way. This statement is true whether we are expressing ourselves by going to see the Backstreet Boys on the Vegas strip or discussing personal issues with a therapist. Some things can only occur when we can be confident that our disclosures and behavior will be kept hidden from the public eye. Standards related to confidentiality are enshrined in the ethics codes of all mental health disciplines precisely because these standards allow our clients to speak about their issues in a candid manner without fear that their disclosures could be used to harm them.

Unlike visitors to Las Vegas, mental health providers are expected to keep accurate records of their behavior and disclosures while in their role as a provider as well as the behavior and disclosures of their clients. Creating and maintaining accurate records is important for many reasons including, but not limited to, continuity of care and provider accountability. However, balancing the need to keep accurate records with the expectation of confidentiality can be tricky.

Over the years, I’ve noticed that many of my Service member and Veteran clients have also struggled to find a balance between disclosure and maintaining confidentiality when it comes to discussing their own experiences. Sometimes, this can be a significant barrier to successful treatment. Information that is strongly tied to a presenting issue can also be information that the Service member or Veteran has either agreed never to disclose, that is embarrassing and painful to discuss, or that the client fears will result in punitive legal action if disclosed. For example, some Service members sign confidentiality agreements stating that they may not disclose details about activities, missions, deployments, and other details of military service. What if one’s traumatic experience is one of those “details” that may not be disclosed?  Other Service members may have witnessed, participated in, or were unable to take action to stop events that may had led to a moral injury (e.g., accidentally killing civilians in a combat situation). There may be concern that disclosing these events may lead to harsh legal problems. What is a client to do in these situations? What happens when the information that was supposed to “stay in Vegas” also has to “leave Vegas?”

Luckily, there are few relatively simple things that savvy mental health providers can do to help Service members and Veterans to navigate the “Vegas dilemma” :

●It can be helpful to devote some extra time and attention to the informed consent process. Clearly explaining your obligations in terms of documentation, maintenance of confidentiality of disclosures, and specific limits of confidentiality, AND re-explaining these obligations can go a long way. Tailoring this discussion to your client’s specific concerns is imperative.

●Remind your client that therapy is a special situation in which disclosures of client information is prohibited except in special situations (and clearly explain those situations). It is often a relief to clients who have a moral injury to learn that mental health providers are not obligated to report past actions that may be considered illegal in a combat situation.

●Describe the nature and level of detail that you are obliged to document in your client’s medical record. Many clients are relieved to hear that their medical record needn’t include a verbatim account of their disclosures during session and that sensitive events can be described in general details.

● It can also put your client at ease to know that they can verify your statements about documentation standards by reviewing their records. Furthermore, it can be helpful to have a discussion with your client about their preferences regarding the way an event will be described in the medical record.  Rather than stating, “client reported that he discharging his weapon and accidentally killed a civilian,” you might inform your client that you will write, “client discussed an upsetting event that occurred in combat” in their record.

●Remind clients that they are free to describe their experiences in as great, or little, detail as they wish. When circumstances in therapy that might necessitate talking or thinking about specific details of an experience (e.g., imaginal exposure during the course of Prolonged Exposure therapy), remind your client that details about their experience of the event are often more important than information about where, when, and the circumstances in which the event occurred.

Now that we’ve discussed some options for responding to clients’ concerns about disclosing sensitive information from their military experiences, let’s revisit the client statements that introduced this blog. Following each statement below will be one possible therapist response that would hopefully begin a useful conversation that ends with the client having a greater understanding of his or her options.

“I just can’t talk to you about it. I signed that paper saying I would never talk about what we did out there.”

Therapist: “Seems like there is something important that you need to discuss, but you are concerned that telling me about it would violate an important commitment. Is there a way that we can talk about the situation in a way that maintains the spirit of your commitment and also allows you to do the work that needs to be done in therapy?”

“You don’t understand. People died who shouldn’t have died. If I talk about it, you might have to report me.”

Therapist: “It might help me to understand your position better if you could say more about your concerns. Would it be helpful to review your confidentiality rights, as well as the limits of confidentiality, again? For example, did you know that I am not required to report any past criminal activity that a client admits to me during therapy?”

“The things I need to talk about are the things I CAN’T talk about.”

Therapist: “That sounds like a really upsetting dilemma. Is there a specific reason that you can’t talk about these things?”

Of course, these are just a few generic examples that may give you some ideas for addressing the “Vegas dilemma” with your clients. Every client is unique, and it is important to devote adequate time to assess your client’s specific concerns. This will give you and your client the best chance of finding the right balance between disclosure and confidentiality.

Thanks for reading! I hope that this blog has been helpful. Please log and leave any comments below or on the CDP Facebook page.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Andrew Santanello, Psy.D is a licensed, clinical psychologist and CBT trainer at the Center for Deployment Psychology.