Almost everything you say in therapy is confidential. Therapists are legally and ethically required to protect your privacy. They can’t tell your friends, your family, or your boss what you talk about. They can’t gossip about you to other therapists or post about your sessions online.

But there are a few specific situations where therapists are required to break confidentiality. Knowing what those are will help you feel more comfortable being honest.

When you start therapy, your therapist will explain their confidentiality policy. Usually this happens in your first session, and you’ll probably sign paperwork acknowledging you understand the rules.

Everything you share in therapy is protected by law. In the United States, therapist confidentiality falls under HIPAA, which is the same privacy law that protects your medical records. In Pennsylvania, therapists are also bound by state laws and their professional ethics codes.

This means your therapist cannot share information about you without your written permission. If your spouse calls and asks what you’ve been talking about, your therapist can’t tell them. If your employer wants to know if you’re in therapy, your therapist can’t confirm or deny it. Even basic stuff like whether you’re a client at all is protected.

Most therapists take privacy seriously beyond what’s legally required. If you run into your therapist at the grocery store in Rittenhouse Square or at brunch in Fishtown, they won’t acknowledge knowing you unless you say hi first. They don’t want to accidentally out you to whoever you’re with.

There are a few situations where therapists are legally required to share information. These are rare and specific, and most people never encounter them. But you should know what they are.

If you’re at serious risk of hurting yourself. If you tell your therapist you have a plan to kill yourself and intend to do it, they may need to take action to keep you safe. This doesn’t mean every mention of feeling hopeless or having dark thoughts gets reported. Therapists are trained to assess risk. Saying “sometimes I wish I wasn’t here” is different from saying “I bought a gun and I’m going to use it tonight.” Most conversations about suicidal thoughts stay completely confidential and become part of your therapy work together.

If you’re planning to hurt someone else. If you make a specific, credible threat against a specific person, your therapist may be required to warn that person or contact authorities. Again, this is about immediate danger, not venting about how much your coworker annoys you.

If a child, elderly person, or dependent adult is being abused. Therapists are mandated reporters. If they learn that a child or vulnerable adult is being hurt or neglected, they have to report it to protective services. This applies whether you’re the one being abused, you’re the one doing the abusing, or you know about abuse happening to someone else.

If a court orders your records. In rare legal situations, a judge can order your therapy records to be released. This usually only happens in specific types of court cases. Your therapist will typically try to protect your privacy as much as possible even in these situations.

That’s pretty much it. Those are the exceptions. Everything else stays between you and your therapist.

A lot of people worry that if they talk about certain things, their therapist will have to report them. Let’s clear up some common concerns.

Can you talk about suicidal thoughts? Yes. Therapists want you to bring up suicidal thoughts so they can help you with them. Our therapists in Philadelphia hear these kinds of thoughts regularly, and talking about it doesn’t automatically mean you get reported or hospitalized. Your therapist will ask questions to understand how serious the thoughts are and help you make a safety plan.

Can you talk about past mistakes or crimes? Yes. If you shoplifted when you were 19 or cheated on your taxes five years ago, that’s confidential. Past actions aren’t typically something therapists report. They’re there to help you process your experiences, not judge them.

Can you talk about affairs or relationship stuff? Yes. Your therapist won’t tell your partner what you’ve been up to. Couples therapy is a little different since you’re both in the room, but individual therapy is private even from your spouse.

Can you talk about illegal drug use? Yes. Therapists don’t report drug use to the police. They might want to discuss how substance use is affecting your life, but that’s therapy, not surveillance.

The goal of confidentiality is to let you be completely honest. Therapy only works when you can talk about the real stuff. Therapists understand that people have complicated thoughts and histories. Nothing you’re dealing with is going to shock them, and your therapist isn’t going to judge you for what you share.

If you use insurance for therapy, your insurance company will know you’re receiving mental health treatment. They need basic information like your diagnosis and dates of service to process claims. But insurance companies can also request your therapy notes if they want to verify treatment or audit claims. This doesn’t happen often, but it’s within their rights when they’re paying for your care.

This is one reason some people choose private pay therapy instead of using insurance. There’s more privacy when insurance isn’t involved. Your therapist still keeps records, but nobody else sees them unless you give permission.

If you’re nervous about confidentiality, ask about it. A good therapist will be happy to explain their policies and answer your questions. You can ask things like who has access to your records, what they would do in different situations, and how they handle communication outside of sessions.

You have the right to understand how your privacy is protected before you start sharing personal information. This isn’t a weird or awkward thing to bring up during your consultation. It’s a smart question that shows you’re taking therapy seriously.

We offer in-person therapy in Philadelphia and Haddonfield, with online sessions available throughout Pennsylvania and New Jersey.

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