What your therapist can and cannot share

Can a therapist tell anyone what you say?

Generally, no. A therapist keeps what you say in counseling confidential and does not confirm to your family, your employer, your pastor or your neighbors that you are a client unless you give written permission. The federal HIPAA Privacy Rule requires a signed authorization for most disclosures that are not about your treatment, payment for it, or the running of the practice, and professional codes go further. The National Association of Social Workers Code of Ethics, for example, says social workers should protect the confidentiality of all information obtained in professional service except for compelling professional reasons.

The same code says therapists should discuss the nature of confidentiality and its limits with clients as soon as possible. So you should hear all of what follows from your own therapist, in their words, in the first session. This page is a general summary, not legal advice, and the details vary with a therapist's license and setting.

The exceptions, in plain terms

These are the situations in which a therapist in the Carolinas may, or must, share information without your permission:

• Suspected abuse or neglect of a child. In North Carolina, G.S. 7B-301 requires any person or institution with cause to suspect that a juvenile is abused, neglected or dependent to report it to the county department of social services. That duty applies to everyone in the state, not only therapists. South Carolina's Section 63-7-310 names mental health professionals among those who must report.
• Suspected abuse, neglect or exploitation of a disabled or vulnerable adult. North Carolina's G.S. 108A-102 requires any person with reasonable cause to believe a disabled adult needs protective services to report it. South Carolina's Section 43-35-25 lists mental health professionals among mandated reporters for vulnerable adults.
• A serious and imminent threat to someone's safety. HIPAA permits a provider who believes in good faith that disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public to share information with someone reasonably able to prevent it, including the target of the threat.
• A court order. North Carolina's privilege statutes for social workers (G.S. 8-53.7) and counselors (G.S. 8-53.8) protect what you tell them, but a superior or district court judge may compel disclosure if the judge finds it necessary to a proper administration of justice.
• Payment. If you use insurance, your insurer receives the limited information it needs to pay claims. That has its own page: insurance, records and privacy.
• Your own request. You can authorize your therapist in writing to talk with your doctor, a family member or anyone else, and you can limit what is shared.

Is there a duty to warn in North Carolina?

Not as a legal requirement. Some states follow the California Tarasoff decision and require therapists to warn or protect an identifiable person their client has threatened. North Carolina has no statute requiring that, and in Gregory v. Kilbride (2002) the North Carolina Court of Appeals declined to recognize such a duty. The National Conference of State Legislatures lists North Carolina as having no duty to warn.

That does not mean a therapist must stay silent in an emergency. North Carolina's mental health statute, G.S. 122C-55(d), allows a responsible professional to disclose confidential information when there is an imminent danger to the health or safety of the client or another person, or a likelihood of a felony or violent misdemeanor. HIPAA permits similar disclosures. In South Carolina, Section 19-11-95 allows a licensed mental health provider to reveal a patient's intention to commit a crime or harm himself and the information necessary to prevent it.

These rules allow disclosure; they do not require it. Laws change, so if this matters to you, ask your therapist how they would handle it, or ask a lawyer. Whatever the rules, ordinary worries, intrusive thoughts you have no intention of acting on, and talk about difficult feelings are exactly what counseling is for.

What are psychotherapy notes?

HIPAA draws a line between your general health record and psychotherapy notes. Psychotherapy notes are a mental health professional's notes analyzing the content of a counseling conversation, kept separate from the rest of your record. The definition excludes things like session times, diagnosis, treatment plan, symptoms and progress, which belong to the regular record.

Under 45 CFR 164.508, a provider generally needs your specific authorization to use or disclose psychotherapy notes, apart from a few narrow exceptions, and a health plan cannot make your enrollment or benefits depend on your authorizing their release. Your HIPAA right to see your own records does not extend to psychotherapy notes, though a provider may choose to share them. Not every therapist keeps separate notes of this kind, so ask.

What this means in a small town

In Tryon or Columbus, privacy is less about the law and more about chance meetings and shared acquaintances. A therapist will not greet you in public unless you choose to say hello, will not discuss one client with another, and should tell you if an existing relationship means they cannot see you. The pillar page, anxiety and privacy in a small town, covers this in more detail, and seeing a counselor outside your own town weighs the option of driving a little further.

Laura Bass explains confidentiality and its limits at the start of counseling. She works with adults at her main practice in Charlotte and at a part-time office at The Healing Cottage in Columbus; call 704-706-3264 or use the contact page to ask anything about privacy before you book. Questions to ask before you start has a list worth bringing.

If anxiety ever turns into a crisis, or you have thoughts of harming yourself, call or text 988 at any hour. In Polk County, Vaya Health's 24-hour crisis line is 1-800-849-6127. If anyone is in immediate danger, call 911.

Common questions