Ellie Pike:
Have you ever held something back in therapy, not because you wanted to lie, but because you weren't sure if it was safe to say out loud? Maybe you wondered, "Will my therapist tell someone? Could this get me into trouble? Will they to keep meeting with me?"
Today, we are talking about those moments, the tender messy ones where trust is tested, and how to navigate them with more confidence. I'm joined by two brilliant clinicians, Maria Ortiz and Dr. Zoe Ross-Nash from On the Mic with ED Podcast to talk about what therapists are really thinking when you share a hard truth, when they can keep something confidential, and when they have to speak up.
We also break down what informed consent really means, how you can advocate for yourself in the therapy room, and why it's completely okay to take your time before sharing everything. Whether you're just starting therapy or have been going for years, this episode is here to help you build trust, feel empowered, and know your rights. You are listening to Mental Note Podcast. I'm Ellie Pike.
Before we begin, I'd like to more fully introduce our guests and let them explain a bit about their backgrounds and why you can trust their perspectives. Meet Maria Ortiz and Dr. Zoe Ross-Nash.
Maria Ortiz:
My name is Maria Ortiz, and I am a licensed mental health counselor in Fort Myers, Florida. I'm also a recovered clinician, so I have my professional expertise and specialty in eating disorders, but I also have that lived experience, and so in my practice or in my speaking, I try to draw from a little bit of both in attenuated ways.
And I also do a lot of work with adolescents, I have a specialty with athletes as well, but really my main focus is just all things eating disorders, all things getting people into that recovered space, and truly getting their life back.
Dr. Zoe Ross-Nash:
My name is Dr. Zoe Ross-Nash, and I'm a licensed clinical psychologist. I'm actually licensed in both Florida and California, so I have a little bit of a bi-coastal clientele, which is really cool. I specialize in eating disorders and trauma. It's what I focused my entire doctorate on. Did my dissertation on it as well, specifically the function of eating disorders and trauma.
And similar to Maria, I just have immersed my clinical work in that, and I also do advocacy efforts, and I do training programs for clinicians to become trained in eating disorders just because there are so few of us. And my passion really lies in both clinical work and advocacy.
Ellie Pike:
Well, I'm so thrilled to do this collaborative episode with you all, and there's no one better to talk to about confidentiality and what that looks like to be in a therapy room than the both of you. So I'm really excited to hear both of you dialogue and actually be a little bit more of a fly on the wall in this conversation.
So let me give you a little background on how this podcast idea came to me. So I was talking with someone whose daughter has been in therapy and treatment for years. We're probably thinking, I don't know, I'm guessing 12, 13 years. And this mom was coming to me and saying, "I really wish you would do a podcast on what you can and cannot say in therapy or what the risks are of saying certain things in therapy." And I was like, "Well, tell me more. Exactly what do you mean?"
And she was like, "Well, I just notice a lot of folks going to therapy, even if they've been going for years, still have some things that they're holding back on because they're just scared of what the result might be if they did share it with their therapist." So for example, what if I tell my therapist that I'm using marijuana but I'm also on a medication? Are they going to have to tell my doctor or are they going to stop seeing me? What is the risk of telling them the truth, essentially?
And so it was a really good reminder to me that we need to shed some light on what the therapy room actually looks and feels like for anyone interested in exploring therapy. But then also anyone, even if you're seasoned as a therapist or a family member, knowing how to navigate some of those tricky situations when you're trying to explore what to talk about. So are y'all up for this conversation?
Dr. Zoe Ross-Nash:
We are so in.
Maria Ortiz:
Yep. We are ready.
Ellie Pike:
So let's just start with the basics. So you're both therapists, and I would love for you to describe in your own just non-clinical words, what does it mean to you to be a therapist, and what is your role to the client? I'm going to call on Maria first.
Maria Ortiz:
Okay. So what does it mean to be a therapist? For me, it kind of means everything in the sense that a lot of my story is what brought me here, so my own struggle with an eating disorder in my past. I kind of eventually found what that purpose was for me and that I feel like I can connect and relate to individuals and help individuals in a different way.
It means the world to me if I could even just help one person get a life back is what I thought going into this. If I can help one person get their world back, get their thoughts back, and get their space back and their relationship with food and body, that's what I'm here for. I consider it an honor to be a part of this journey for them. This is probably one of the most vulnerable states of somebody's life, and I consider myself very grateful and lucky to be a part of it.
Ellie Pike:
Awesome. Thank you so much for being here. I know your clients are super lucky. Your turn, Dr. Zoe.
Dr. Zoe Ross-Nash:
Yeah. I actually got a little choked up just at the question then hearing Maria's answer, and yes, her clients are incredibly lucky to have her. But heavy is the title that is therapist, and it means so much more than just being someone who's treating a mental health disorder. It means being an advocate which extends far outside of that 50-minute hour you have with your client.
It means holding space for both compassion and accepting of the client while encouraging them to become their best self and recognizing maybe there are some things that we have to work on. It means having collegial relationships and depending on each other, that those are the relationships that are so special to me. And if we can be the identity of a therapist, not just in that therapy space but outside of the therapy room, I hope that the world become a better place because of that.
Ellie Pike:
I am so grateful that you're both here. And one thing that I'm hoping is that we can equip anyone who's stepping into a therapy room to know how to navigate really tricky scenarios where they're just not feeling confident, where if they're feeling really unsure about what feels safe to talk about.
So I feel like my goal at the end of this episode is that they would feel equipped and ready with some practical tools. So let's just go ahead and jump in. So what is informed consent?
Dr. Zoe Ross-Nash:
Yeah. Informed consent is basically understanding that you recognize both the benefits and risks of entering therapy. With any treatment, there's going to be some sort of risks, and there's limits of what you can or cannot share without potential disclosures. And each state has different disclosures depending on where the client is physically located, so it's really important for clients to know what those state-specific laws are.
Maria Ortiz:
The way I describe it to my clients when they come in that first session, one, they've already received the paperwork, they've read through the informed consent. But I ask, number one, do you have any questions about it? And I try to lead off with that in case there's anything glaring for them.
But then I basically explain in the terms of anything and everything that you say in here is confidential except for these reasons, and I really just lay them out. And from there too, I try to explain some of the why, that my biggest priority is making sure that you are safe, making sure that other people in your life are safe, making sure that it is ethical to continue without breaking those confidentiality barriers.
Ellie Pike:
When we talk about it, I am putting myself back in the shoes of someone as a therapist or a client, and that informed consent conversation usually just is part of the beginning of therapy, right? And then there's a lot of folks who've months down the road built trust with their therapist or just continue on therapy for years, and then that conversation feels so long ago that you can't remember the details.
And so I think it's really important for everyone to know that when you enter into a therapeutic relationship, you do sign an informed consent. You might forget about it, but you can always come back to it, and you can always ask your therapist, "What was that?" Or, "Let's go back and discuss that because I need a refresher." Because I think it can often just get lost in the mix of things, and it's so incredibly important to be reminded of what essentially is included in the therapeutic environment.
Maria Ortiz:
Right. And I think whenever I've had clients say, "I'm debating if I'm going to tell you something or not," if I ask, "Does this have to do with confidentiality?" And if they say yes, then I actually ask some questions or we go through that informed consent. So I'll basically state, "Well, anything that you're about to say, if it has to do with harm to self for other people or imminent harm to self for other people, I would need to disclose that. If it has to do with abuse of a minor or an elderly person, then I would need to disclose that."
And one, you can usually tell by a face if those fit, but then sometimes they might have follow-up of, "Well, what does that mean, self-harm?" And so then I kind of further explain, "Am I going to be concerned that you are at risk of harming yourself when you leave my office? Yes or no? What is your ability to contract to safety following your disclosure? What is your level of insight into the harm? What is the fatality associated with the self-harm?"
So a lot of those things, I try to tell them, that there is a gradient there, and some of it even could be a risk. But I try to tell them just cards on the table, "These are the incidents that I may or may not need to disclose, and what would you like to move forward on?"
Dr. Zoe Ross-Nash:
Sometimes I explain that in layman's terms. It's if I feel that you are going to leave this office today and you cannot maintain your safety or you cannot maintain the safety of someone else, then that would be time that I would have to break confidentiality and contact the appropriate people.
Ellie Pike:
Well, and when you say that, what does that actually mean to contact the appropriate people?
Dr. Zoe Ross-Nash:
It depends on the circumstance. So if it is an older adult, it might be adult protective services. It depends on the location. If it's in a hospital, at least in California where I'm licensed, it would have to be the police. If it is a minor, it would have to be child protected services.
Ellie Pike:
Well, and I think that it's really important to think about the intent behind it where you as the therapist are held liable for making the best decisions that you can with someone else's information and to ensure their safety to the best of your ability.
And so as folks are navigating what feels safe to talk about with my therapist or not, what do you think about the idea of someone coming into your office and saying, "Hypothetically, if I said this, X, Y, and Z, what would you have to do?" How would that make you feel as a therapist, or would that feel like a helpful tip for someone navigating situations like these?
Maria Ortiz:
I think that that would be helpful if somebody could kind of produce a situation that's maybe similar to what they'd want to state. What I will say if they say something like, "Hypothetically, I was considering harming this person, what would you need to do?" That's where we also bring in things like clinical judgment. So then if I'm like, "Well, yes, I would need to actually probably report that."
If they say never mind, it is actually then within our scope that we do need to use some clinical reasoning and we need to make a best decision on, "Okay, was there some seriousness to this? Do we know the human they're discussing? Is there high risk associated?" But I think initially kind of as that camouflage, you could ask a general statement: "Harm to others, tell me the rules. Hypothetically, tell me about those." And that's where we would discuss intent, access, plans, all of those things.
And I'd probably let them know. I'd say, "Well, hypothetically," I'd ask, "Is there a plan in place?" I'd ask, "Are they accessible?" I'd ask, "Do we have a motive?" I would ask, "Do we have a safety plan in place to not engage with this behavior?" And so I would probably hypothetically ask them some questions back as well to kind of continue that investigation on what's going on.
Dr. Zoe Ross-Nash:
What Maria was talking about with that clinical judgment goes to the part of informed consent that it is abuse and also suspected abuse. So it doesn't necessarily just have to be, "Oh, I disclosed this," but if your therapist is using their intuition and it feels like something else is going on, that is enough to make a report.
Ellie Pike:
So I think that is really important to understand in what circumstances it's mandatory reporting is necessary, right? So then that comes down to most cases of abuse, especially with children or elder adults, and then if you're harm to yourself or others especially.
And then aside from that, there's a lot you can talk about in therapy. They would not have to be breached unless something was subpoenaed by a court. And even then, clinicians have to be extremely careful and thoughtful and should have the client in mind when they're writing their notes.
And so I'm thinking about all of those other scenarios of, "Wow, can I talk about this, that, and the other"? And I'm wondering what kinds of conversations come to your mind when I say that? When you notice a client is nervous and then they've started to talk about something that you're like, "Wow, that was really holding you back," but we really came to a clearer space and built trust in the relationship?
Maria Ortiz:
The first scenario that I think of has to do with eating disorder behaviors. So we obviously outlined those true breaches of confidentiality and when they need to happen. When it comes to the eating disorder space, there's also a level of severity with an eating disorder that could indicate a higher level of care.
So where I see this topic come up is people might be hesitant to maybe report that their purging has relapsed. They might be hesitant to report what level of restriction they're engaging with for fear that the team might say, "Okay, time for a higher level of care."
So that's where I kind of see that come up, and that's where I try to keep everything kind of on the table and clear of what our expectations are, what needs to happen for us to go to a higher level of care, what would indicate we could step down to less frequency of sessions. But I would say that's what I see that's kind of outside of those, the self-harm and the abuse.
I do see a lot of concern with my clients on, "If I share this, is she going to tell my dietician, and then are they going to decide that I need more help, and are they going to phone mom?" But again, I really like to just be very honest with my clients from the beginning and state, "These are the parameters that I feel comfortable working with you on an outpatient level and these are the things that we need to be able to discuss if they came up."
Again, it's another thing though, if people state, "Man, I'm engaging with this behavior at a severe amount," what is their level of willingness to bring that down? What is their ability to engage with treatment interventions? All of that would play a role on what decision would be made next.
Ellie Pike:
Well, I think you bring up a great point there about the treatment team piece, so maybe we even pause and talk about that for a second. So whether or not you're in eating disorder treatment or other mental health treatment, if you're working with a treatment team, meaning an outpatient provider, and then maybe a dietician or a psychiatrist or a medical doctor, and there's releases of information signed so your care team can actually speak to each other about you, can you all share a little bit about when does it feel appropriate? That you're like, "Oh, I'm going to share this with the doctor and the dietician," and to what level?
Dr. Zoe Ross-Nash:
So you might see release of information also be called an ROI. So we have a lot of acronyms within the therapy role, and it can feel really confusing, so we just want to demystify that, an ROI. And your therapist, dietician, PCP, psychiatrist, should all be working together to make sure that we're on the same page and giving you the best care possible.
That being said, in the consultation space, we should only be sharing what is relevant to the consultation, what is relevant to the presenting problem. And we should be honoring the release of information only disclosing what is necessary because what is said in that therapy space is vulnerable and maybe we didn't want our dietician to know.
And to hold the dialectic, sometimes especially with eating disorders, the eating disorder might utilize different people and share different things to another person than they would to a different person, and then it gets really messy because you end up cooperating with the eating disorder.
Maria Ortiz:
So a practice that I engage with with my work is basically keeping my clients informed. So I will state usually, "Hey, I'm going to send an update to so-and-so on your treatment team. Here's what I'm planning on saying. What are your thoughts on this?"
With dieticians or PCPs, other people that maybe don't need to know so much therapeutic information, I will share what's relevant for their practice and their expertise. So they're struggling with their meal plan, these are the behaviors that they're still engaging with, these are the meals they're struggling with, but I'm not going to share the topic that they brought up with their family, right? Their family dynamic or something of that nature.
Granted, if I think it's important that the team knows, "Hey, there's something else going on in their environmental space that's impacting their ability to engage with treatment," I very forthcomingly ask my clients, "Are you okay if I let so-and-so know that there's something going on within the home dynamic?" Typically speaking, they're going to say yes, but if they said no, I actually would honor that. And ideally, as we continue to work through, I would share with them the importance of maybe people knowing that there are other barriers in place and kind of go from there.
Where there's a difference where I may be, actually, I think I would always still tell my client, now that I think about it, I've actually always told my client, even if they don't like it, but say I'm like, "Hey, you have lost X amount of weight, you're engaging in these behaviors." And if they say, "Please don't tell anyone", that's kind of where I go back to our initial conversation of we work on a team for a reason, these releases are in place for a reason, and this has to do with your health and safety.
And typically, actually, I've seen there, even if there's some frustration initially, I have had so many clients come back later and say, "Thank you so much for intervening." There's usually a small part of them that's like, "Help me," but their exterior is like, "Keep it silent." So I really just try to make it a collaborative conversation on how do we meet your goal? And your goal is that you want to get better, so it might take divulging some information to others.
Dr. Zoe Ross-Nash:
And the ROI doesn't have to be complete and utter openness to your chart. It can be specific things. So let's just say you are someone older than 18 and maybe a parent is involved in your treatment. The ROI can just be specifically for finances or adherence to meal plan or attendance, so there are ways that you can specify something that was more within your comfort.
Ellie Pike:
I really appreciate you mentioning that because there are folks over the age of 18 that their parents are like, "Hey, I'll pay for treatment," and then it makes them feel like they are entitled to receiving information about their treatment experience, and that's not true at all. So I think that's really important, and that might be one of those tools in the toolkit that someone leaves with today is knowing what they're signing and that they can actually specify the type of information that you can share with others as their therapist.
So I want to go back to something that Maria, you mentioned, and actually, Zoe, you did too, about how someone might come in presenting with an eating disorder and they might tell different things to different providers, or they might actually not be truthful or at least not fully forthcoming about their behaviors in the therapy room.
And I see multiple layers to this, and I think there's a layer of just trust in general, which is a foundation of all therapeutic relationships. But then specifically with an eating disorder, I really see how the function of the eating disorder is at the forefront, right? Because the eating disorder doesn't want to go away. The eating disorder doesn't want to be found out.
So I'm curious how you approach that with the individual where it probably takes some separation, between seeing the individual and then also seeing the eating disorder over here, who is more of the manipulative one. It's not necessarily the human that's trying to manipulate the situation.
Maria Ortiz:
This is where externalization is so important, that our clients are not walking eating disorders. They are walking humans, walking people, that happen to struggle with eating disorders. And you're absolutely right. The eating disorders are the part that may have some manipulation, may have some lying tendencies, may have some secrecy because eating disorders thrive on secrecy. If people know the eating disorder is there, they're going to try to take it away, so it's like, "Keep it quiet," right?
There's a couple things that I do in my practice, one of them being I will just straight up ask the question, "Is there anything that you haven't shared with me before? You don't have to say what it is, but is there anything that you haven't shared?" And more oftentimes than not, I actually will get a nod, and I'm like, "Okay." And then I start talking about what are the barriers to sharing? "Well, I'm worried about how you'll react," or "Well, I feel a lot of shame about something."
We can actually then work on the function of the secrecy to actually make them feel a little bit more comfortable. But the other thing I remind them, this is your space and this is your time. You're allowed to guard that, and I will honor that. And sometimes even just reminding them, "I'm not going to force you to say anything," actually can create that comforting space, and maybe next week they come in, and you're like, "Remember that thing? I'm ready to share."
As far as sharing with different providers different things, I think that we remember that the eating disorder loves control. So maybe one day, the ED gives them the green flag, "You can share this piece of info but no more," but then the next day, they see their dietician, and it's like, "Okay, fine. You can give this piece, but don't give them to the same people," right? That's where it can help though the individual that at least now the treatment team has multiple answers that we can now communicate and converge together, and that's the importance of those ROIs.
I think a lot of it too is just kind of overall sense of safety. This is their most guarded thing in their life. It might even feel like a friend to them, it might even feel like a part of them, that now we've got so many different providers asking so many vulnerable questions, sometimes, gosh darn it, they might just want to not share something that day, and it makes them feel safer. But talking about the aspect of secrecy I think is super important in this space as well.
Dr. Zoe Ross-Nash:
I love the way you approach that, Maria. I adopted it after you and I had a conversation around this once. But I handle secrecy differently depending on the stages of treatment. So in the beginning of treatment, if it's an intake, and I can tell that they're not really wanting to share something, I said, "Hey, we met 15 minutes ago. It's really okay." I try to make levity of it. I'm a stranger. You're still getting to know me.
I'll be like, "Hey, we met 15 minutes ago. It's quite all right if you don't want to share something with me. And actually, I haven't earned your trust yet to hear all of your stories, so take your time, figure out when and how you would want to share, if you want to share with me." And then if there is secrecy later in treatment, we approach it in a different way of what was the function of the secret?
And I actually recently had this with a client where the severity of the eating disorder had spiked. She hadn't shared it with me for a couple of months, and I was really taken aback by the severity, so I probably didn't handle it as well as I wanted to in session, also remembering your therapists are human too and we care about you.
And after I spent some time reflecting on the secret and why it was held on for so long, I actually recognized how skillful her engaging in secrecy was in her family dynamic and her family of origin. It was really helpful and functional for her to keep secrets. It kept her safe. But in the therapeutic space, it wasn't helpful for her. It wasn't adaptive or skillful. It actually kept her from being able to get better.
So recognizing that it's not a personal attack on you if you're a therapist, and also, for clients, it is totally okay if you want to keep secrets. And doing that dance of, "Okay, it wasn't beneficial in my therapeutic space, but it was beneficial with my family space," or whatever the space is, and recognizing there can be two truths within the secret.
Ellie Pike:
I think that you're speaking to something that reminds me of just a broader aspect of therapy that I think is so key is that when someone comes into therapy and then they share something with you as the therapist, you're not going to just be like, "You need to stop doing that," right? I mean, some might, but that they are not a good therapist.
So I think that that's a really important piece here is someone might come in with something that they're fearful of sharing like, "Hey, I'm using X, Y, Z drugs or alcohol," or, "Hey, my relationships are pretty promiscuous right now," right? One, there is a fear of judgment oftentimes, but then sometimes there's just the fear of being told, "Don't do that anymore," because that's what a lot of relationships do to us is they tell us what to do, but a therapeutic relationship should look different.
And so when you're describing that, digging into the function of, or maybe even the word purpose might not be the right word, but yeah, the function, like what does this behavior do? I think it's really important to know that that's where a lot of trust can be built.
So say Zoe, if I came to you and said, "Hey, I'm really struggling," or maybe it doesn't even feel like a struggle, "I'm using drugs every night," the relationship from there, you and I can actually talk in open dialogue about something that's happening that I'm currently using drugs every night. And I have a feeling you would dive into, "Okay, let's talk more about it. What are the risks and the benefits, and what function does that hold for you?" So as we're talking about that, what comes to your mind, Zoe, as far as how you would handle it?
Dr. Zoe Ross-Nash:
So Dr. Susan Heitler says people don't like to be told what to do. So if you are in therapy and your therapist says, "This is what you have to do and you've got to do it," you're going to have resistance to it.
So I really like to use a motivational interviewing technique where we weigh out the pros to the behavior and the cons to the behavior. What's drawing? You wouldn't do it if it wasn't helping in some way, so what is drawing you to the behavior? What is it serving in your life? And that's really helpful in eating disorder treatment because it is really beneficial to befriend the eating disorder because when you befriend it, it's a little easier to challenge it and chip away at it.
So we don't want to immediately shame the behavior because shame causes secrets, and that is really heavy to hold. And if we are able to have this open space of we're going to talk about all of the hard things to say out loud and it's going to be okay, that makes clients much more open to disclosures.
Maria Ortiz:
I think some other techniques as well that you can use is using that verbally, it can be so hard to spit out something. So something I can think of, one client in particular, she wanted to share more, and I could just tell that, but she just couldn't.
And so I just gave her a whiteboard one day, and I asked her certain questions, and I said, "You can just draw a smiley face or a frowny face." And that actually gave me so much info, and she didn't have to share anything. But then I also said, "Okay, are we open to a yes or no?" So then I could ask that info, and before you knew it, she actually got to where she could write kind of full sentences for me and flip around the board. Before you knew it, she could actually even then read off the board, and then we actually were able to just engage with dialogue.
But sometimes even writing things down, something else I've done with some clients before, if they're like, "Yeah, there's just something, I can't do it," I ask, "Are you willing to write it down and then not read it to me?" But they're sharing it in the therapy space, meaning in the therapy room, they wrote it down cognitively. They didn't have to say it out loud yet, but then I asked them, "Can you please bring it with you?" And before you know it, someday they're actually willing to read off of it.
There's something that actually in my relationship with Zoe that has just been so insightful to me and it shows the importance of colleagues and connection, and all of this was I remember one day where we're discussing something like this, and Zoe said, "I pull from the lens that they're going to tell me." And I just remember being like, "I pull from the opposite lens. I pull from the lens that they're not going to tell me."
And I think it was really important that we had that discussion because it kind of opened my eyes to my own biases, right? So in my time struggling with an eating disorder, there were actually certain things I never told a therapist. To this day, I think I would if somebody asked me, it doesn't come up in my life anymore, but there were some certain things that I actually held onto.
I have no idea if those therapists had an inkling, I don't know, but that showed then my own bias from my history was presenting itself in my own professional relationships. And it really helped me to kind of look and go, "You know what? Some people might not be saying things, but some people might just be telling me all of it."
And I think that's just it shows the importance that we seek consultation, we seek supervision, all of those things, acknowledging that every single client is going to be different. Some client might tell you every darn thing, and some clients might have more than one secret, but we still approach it from an aspect of compassion. We approach it as, "This is still your therapy and your space. You are actually in control here," and reminding them of that, but also kind of, as Zoe said, "It's okay to kind of challenge."
And sometimes, we might even be taken aback. When that secret gets released, we might even have our own reaction of, "Oh my goodness." And I think it's okay to be human. I don't think that we need the answer of, "Thank you so much for telling me, that was so hard." I think we can say that and be like, "Wow, that kind of caught me off guard," you know?
We are humans first. Yes, we are therapists too, but it's kind of the same idea as our clients. Our client, they have an eating disorder, we are humans, and we happen to be a therapist.
Dr. Zoe Ross-Nash:
Yeah. Maria, thank you for acknowledging our work is so special to me. So as Maria shared, she has lived experience with an eating disorder. And while I don't, my mom is in recovery from an eating disorder, and I watched a conversation between Maria and my mom about secrets within eating disorders.
And as they were chatting and they had similar behaviors, they were both like, "We thought we were so unique and so different and so slick," and meanwhile your therapist knew what was going on. So even if you think you're holding a secret in therapy, there's a good chance your therapist has an inkling or does know.
Ellie Pike:
I can so appreciate that, and that's why it's so bizarre. You could have various folks with very similar presenting issues that grew up on separate islands with no contact with each other who have very similar context to what's happening in the world, and it's fascinating that that's even possible. But yes, a good therapist who's had experience is going to be able to read in and connect the dots on individuals, but also be able to temper wanting to know with balancing that with when the individual feels safe.
And maybe even asking. I know that that was something that I would even say is, "What would make you feel like you could trust me more? What would make you feel safe enough to share X, Y, and Z?" Having the client feel in control enough to be able to say, "This is what I need," is so incredible because if a client can come into therapy and feel like they can feel heard and advocate for what they need, then that is so incredible because they can take that outside of therapy and practice that in their other relationships.
Dr. Zoe Ross-Nash:
So Maria works with more acute eating disorders, and I work with more acute suicidality, and also recognizing your therapists have heard it, seen it, dealt with it. So honestly, when I hear a client who's experiencing suicidality, I'm like, "Okay, grass is green, sky is blue. Let's figure out a way to help you." So it kind of takes the weight of the newness or the shock value of a secret too.
Maria Ortiz:
Absolutely. I think a common one that I see, if I think of things that are later divulged in my work, it is typically around certain behaviors, and one of them that comes to mind is binging. I will assess for all EDB haters, assess for different things initially and continually, and later down the road, they'll divulge the secret of, "I've been binging." And I'll kind of nod and be like, "Well, yeah. That makes sense. I kind of figured based off a lot of reasons." Sometimes I say that out loud, sometimes I don't, and just say, "Thank you for sharing."
But there are certain nuances, like Zoe said, that myself and her mom kind of had a moment on where we're like, "We thought we were so slick." Little did we know true pathology of an eating disorder told our therapist what the heck was going on. We're like, "Whoa, this is our little secret."
So it's really important too, that people think they have this centralized view of their disorder as, "Nobody else has struggled like this." And I think that's kind of actually even the power of a group space. When they hear somebody else say something that was in their mind, they're like, "Oh, shoot, that's not just a me thing. That's an eating disorder thing."
But I think it's important. I always tell clients, I'm like, "Try me. Try to catch me off guard. I'd love for you to catch me off guard." And they can tell by the look on my face when they say it. I'm like, "Nope, this just sounds like a part of my day and what I'm here to help you with, and I'm so appreciative that you felt safe enough to share."
Ellie Pike:
I love that. And what a relief it is to be that client that's like, "Oh, it's not as heavy as I thought it was." And the pain of the anticipation was probably greater than the actual experience, but it was important that they built that trust first.
And I like what you said, Dr. Zoe, earlier. You were talking about the levels of where you are in care, and it's probably really important that someone doesn't divulge everything the first time that they're there. And teaching someone to have some of those boundaries is really important for the relationships outside of the therapy setting too.
So say I was the person who did a hit-and-run, right? I hit another car, I decided to leave, I did not stop, I didn't check on anyone, and this is the burden that I've been carrying around. So if I was your client and I told you this, what would you do with that information?
Dr. Zoe Ross-Nash:
Nothing. I'd process it. It's not within our requirements to report. It's if there is potential abuse or a potential crime occurring.
Maria Ortiz:
I think people are always shocked by the fact that you could come into the office and say, "You know that guy all over the news? I killed him." And we could not tell a darned soul. Where it changes is if one were to be subpoenaed by a court of law or, two, if you then follow up with, "You know what? And I really liked it, so I'm going to kill again."
That's where it becomes an impending harm. Especially if they name somebody, that's where we have, especially in Florida, or that idea of duty to warn. So if we actually get a name that would be harmed, it's actually within our scope to reach out to that human as well as authorities.
Ellie Pike:
And I think that this is a really fascinating piece of the therapy world. It's your job is to protect other humans who could be in danger right now or to protect your client if they are currently in danger. And then aside from that, unless something is subpoenaed, it probably just kind of sits there, right?
So if I came in and said to you, "Hey, in 2019, I murdered someone," once again, you do nothing with it, right? We process it. I'm not saying anyone should go and murder anyone, but what I'm thinking of is, once again, we care, right? We care about the humans that are in front of us, and what an incredible safe space to be able to offer someone to say, "Hey, you can come and tell me just about everything," and it's probably not going to go anywhere. When you are documenting in a therapy session, what are you documenting and why? And who does that go to?
Dr. Zoe Ross-Nash:
So it depends if you take insurance or if it's private pay. With insurance, sometimes your therapist has to write certain things to get approved by your insurance for the claim and even has to justify amount of treatment. Whereas with private pay, your therapist might have more flexibility.
Maria Ortiz:
Yes. So an example is that I am private pay only, meaning I do not have to send my treatment notes to anybody, I do not have to send a treatment plan to anyone. All of that literally stays within the confines of my electronic health record.
So what I am writing down in my documentation are pertinent things that I need to know about what happened in that session or that are good reminders for me, topics that came up, maybe some homework that we were thinking about or working on. But at least for myself speaking, I try to keep my notes very sparse. Even as I take them, I try to take them in a manner that is keeping confidentiality in mind, and I'm not divulging the entire conversation or that entire session. I'm really just writing down some key points that are reminders for me.
But again, that is different. Since I don't have to kind of ask for approval for more sessions or anything, I'm able to just document truly what is needed for my own memory as well as my ability to continue with productive care.
Ellie Pike:
So when you talk about trying to keep confidentiality, I assume you're talking about, "Well, in case we were subpoenaed," right? These notes don't have to go anywhere until maybe they do. It could be in a custody battle or in a divorce, or who knows what could happen where if the courts subpoenaed those records, that's when you would have to hand them over.
So it sounds like you're being really thoughtful about if these ever did go anywhere, I'm not going to divulge anyone's whole life story. I'm just putting worked on these skills, practiced these skills, discussed this diagnosis, et cetera. Correct?
Dr. Zoe Ross-Nash:
Exactly. I write every note as if my client was reading it.
Ellie Pike:
So what about in cases where someone might work for the military? I feel like that's another scenario where someone else might be seeing the notes aside from just insurance scenarios?
Dr. Zoe Ross-Nash:
This is also a sticky situation. So more or less, even if you are or are not going through insurance, if you are an active duty service member, you are protected under HIPAA.
However, you are potentially at risk to something called the Military Command Exception, where your commander or higher-ups do have access to your notes if it's related to your fitness of duty. So for example, it's why pilots are particularly scared to go to therapy because of even anxiety. IBS is a reason to ground a pilot, so when intersecting pilots and military, it's that much stringent.
Ellie Pike:
I think that we covered a lot in this session and hopefully can equip a listener to be able to think through what is it that would allow me to trust in my therapist? What are the times where they would really breach confidentiality? And then also what are some tips to navigate when I'm unsure if I want to actually talk about something? So before we sign off, I am wondering what is the one thing that you hope to leave our listeners with today?
Maria Ortiz:
The one thing that I would hope to leave our listeners with today is that our true goal as therapists is to help. We are on your side, we are on your team, and we're rooting for you. And the eating disorder can create this illusion of, "Don't tell her, she's against us," right? Or, "She's conspiring against us to do X, Y, or Z."
I really, really want you to hear that we just want to help. We got into this field because we truly want to help this population of individuals. We have expertise in this area, and we truly believe recovery is possible for you. I always tell my clients, "I wouldn't do this job if I thought recovery wasn't possible." That'd be the worst job in the world. Just watch people struggle forever?
So I just want to remind people that we truly believe in the work we do and we just want to help, and unfortunately, we can't help what we don't know. So I encourage you, ask your clinician, what are those rules again? What can I do? If I say this, what happens? I encourage you to just ask. It doesn't hurt, and we will have a candid conversation to help us move forward together.
Dr. Zoe Ross-Nash:
And I think with mine, therapists are bound both ethically and legally in terms of disinformed consent. And there have been many times that I have tearfully written a CPS report because we don't necessarily always want to do that. Breaking HIPAA is the biggest thing a therapist can do, so we don't take these things lightly, and we are bound by ethics to do it sometimes and bound by law to do it sometimes.
So if you are frustrated that a therapist did have to break HIPAA, that is not something they took lightly. It was a huge decision they had to make because it is fundamental to the therapy work.
Maria Ortiz:
I think what also is really hit on is that we care, you know? We're just like, "Oh, okay, we're going to reach confidentiality today." It is not something that we take lightly. Any of those decisions, that's where our humanity comes in.
We're not happy that we have to do that. We want to be able to guard your secrets and guard your life and really honor that vulnerable space. So if for some reason a therapist has ever had to break confidentiality for you, know that typically speaking, it wasn't something we love to do either.
Ellie Pike:
I really appreciate that, and there's probably a few more nuances here and there, but I think the biggest lesson that we've learned today is just to ask your therapist, "Hey, what are you taking notes for? Where are they going to go?" And to feel completely informed from the very beginning so that someone can feel safe and trusting within the environment of the therapeutic setting.
So thank you, both. And if anybody wants to keep following along with Dr. Zoe and Maria, how are they going to find you?
Maria Ortiz:
They are going to find us on Spotify or Apple Music, on On the Mic With ED. We also have social medias also called On the Mic With ED, on TikTok, Instagram, and Facebook, so feel free to follow along with us. We post often. We try to have a diverse amount of content going out, and we'd love to have you as a viewer.
Ellie Pike:
So what do we hope you walk away with? That you deserve to understand your rights in therapy, that asking your therapist about confidentiality isn't rude. It's smart. That it's okay to hold back until you're ready, and that good therapists expect that. They've heard a lot, and chances are you won't surprise them.
Whether you're navigating addiction, an eating disorder, or just trying to figure out who you are, therapy should be a safe place to wrestle with hard things, not a courtroom. So ask the questions, know your state's guidelines, and remember, building trust is a process, not a test. Thanks for joining us, and if this conversation helped you, share it with a friend. You never know who might be holding back something they're just not ready to say.
Thank you for listening to Mental Note Podcast. Our show is brought to you by Eating Recovery Center and Pathlight Mood & Anxiety Center. If you'd like to talk to a trained therapist to see if in-person or virtual treatment is right for you, please call them at 877-850-7199. If you need a free support group, check out eatingrecovery.com/support-groups.
If you like our show, sign up for our e-newsletter and learn more about the people we interview at MentalNotePodcast.com. We'd also love it if you left us a review on iTunes. It helps others find our podcast. Mental Note is produced and hosted by me, Ellie Pike, edited by Carrie Daniels, and directed by Sam Pike. 'Til next time.
