The therapy relationship is built on confidentiality. With certain exceptions, a therapist can’t share what you say during sessions, or even divulge that your name appears in their appointment book. So what happens when you see your therapist (or your psychiatrist, or marriage counselor) out in public? Legally, they can’t take the first step to greet you. But there’s no hard and fast rule that dictates how you’re supposed to act. We wondered how therapists suggest patients navigate these off-hours run-ins, and if they feel just as awkward as we do. Here’s what five mental health practitioners had to say.
Castle Rock, Colorado
As a trauma-informed therapist, I emphasize a lens of safety, empowerment and resilience. Many of the folks I work with have grown up or lived through situations where they didn’t get to choose what felt best to them, and instead left them experiencing powerlessness. With that in mind, starting from our initial conversation about confidentiality and issues like running into me in public, I encourage clients to decide what feels right to them.
From a legal and ethical standpoint, when I see a client in public, I’m not able to initiate contact because I would be breaking confidentiality, and that belongs to the client, not to me. With that said, when a client feels comfortable and chooses to, I enjoy when folks say hello. Alternately, I have been in other public situations where clients are with family members they don’t feel emotionally safe with, and they elect not to say anything at all. This is also totally okay, and often is a great topic for a therapy session later. Ultimately, my hope is clients will honor their needs and live from that place, whether it means saying hello or not.
Psychiatric nurse practitioner
It’s always a good idea to address this issue early on when first meeting a patient or client. Finding out what makes your patient most comfortable and safe allows for mutual respect in any type of provider-patient relationship, setting a foundation for progress and success.
In my practice, I let patients know that if they ever see me in public, they are welcome to ignore me, and I would never take any offense to that. I explain that it may be uncomfortable for them and I respect their feelings. I also let them know that I will never approach them either. In this way, they know not to feel ignored when I do not initiate a conversation with them in public. Sometimes a patient will respond and tell me they have no problem with speaking to me in public and I can surely say hello, so I explain further that if they approach me and say hello, I am more than glad to respond, but that I would never be the initiator.
There are more occasions than not where an individual will thank me and nod understandingly, letting me know that they prefer not to be approached and that likely they will not be approaching me.
In saying that, I find that some individuals may have difficulty with boundaries and may feel it is appropriate to start discussing their concerns or those of their family members in the produce aisle of the grocery store. While the individual may feel very comfortable, it may violate their privacy in ways they do not realize. Additionally, a provider might feel badly when not available to spend time out of the office speaking about a client. Personal time is often already so limited, especially when working in the mental health field, where crisis and medication side effects do not always happen during business hours, but need to be addressed ASAP!
I find that it is helpful to be clear about the therapist-patient relationship at the very start of the therapy process. It is helpful to make it clear to the client that you will not show any signs of knowing someone if you see them in public, and that your priority is their confidentiality and safety. Of course a client can greet the therapist, but this would never be initiated by the therapist, unless it has been previously discussed and the client has given their express consent.
The therapist will follow the client’s lead if they do greet them, but equally a therapist will not be offended or annoyed if a client ignores them. Therapists understand better than most that there are good reasons for ignoring them; for example, they might not want to explain to people they are with that they are seeing a therapist.
If a client does want to greet their therapist in public, it is important to try and avoid extended conversation. Therapy is at its most effective when it takes place within carefully defined parameters, and contact outside of these boundaries can confuse the client-therapist relationship.
Therapists are trained not to acknowledge patients in public to protect patients’ confidentiality unless they do so first, because therapists reaching out puts both in the position of needing to explain to companions (assuming they’re not both alone) who the other person is. Therapists take their cues from patients and don’t feel snubbed if they are not acknowledged.
However, the situation is not as simple as that. I was working in a methadone clinic decades ago when I saw a patient of mine one night when I was on line at the movies with my husband, as she was with hers. I did not acknowledge her, even though she kept looking over at me. In our next session, she was furious and upset, and I’m not sure that for the rest of our time together, she ever got over what she thought was my not acknowledging her because of being ashamed to know her.
In sum, patients should feel free to acknowledge a therapist first in public with the understanding of how the situation might compromise their confidentiality and play out. They should also feel comfortable not doing so with the knowledge that the therapist will be fine with this. Whatever happens, it’s always a good idea to talk about what happened in a subsequent session.
Mark B. Borg Jr., PhD
Clinical/community psychologist and psychoanalyst
New York City
Anyone who has been here for a while will tell you that New York City is a small village. Practicing here as a couples’ therapist and clinical psychoanalyst for the last two decades, I can tell you that I have had all kinds of run-ins with patients in public. And like so many public, unexpected, surprise incidents one might experience as one sojourns from there to here in NYC, there is simply no amount of practice or training likely to prepare you for what is often described as the shock of seeing the keeper of those most secret thoughts and feelings in what feels like the context of your (the patient’s) personal life.
How should they approach me? Let me give you a more general sense of how they actually have approached me. What I hear, often, is that they don’t — they see me, I don’t see them, they have some conflict over the question of should or should not, and they don’t. I only know about it because it comes up as a topic of therapy. One person who I’d been seeing for some time told me that she saw me, freaked out and called a friend, who then counseled her by telling her to simply say hello. A number of times a patient has run into me with family, friends, significant others, stopped me and introduced me — as their shrink, therapist or analyst — to each and every one of them.
As far as how one should approach their therapist in public, if they choose to do so, remember this: Your therapist is bound by HIPAA (the Health Insurance Portability and Accountability Act), professional courtesy and legal ethical standards to not in any way break your confidentiality. Therefore, he or she is not going to approach you, is not going to blow your cover — and, importantly, is not being rude or avoiding you. So the best way to approach your therapist in public is to do as my patient’s friend suggested: Say hello. Most of us will simply return the greeting and look forward to seeing you back in the office.
Responses have been condensed and lightly edited.