Is psychotherapy confidential?

Your choice to engage in psychotherapy,  the contents of what you share in psychotherapy, and the record of your psychotherapy are all protected under the law and by the ethics of the profession. This means that Dr. Garber cannot acknowledge who his clients are, what they say, or the records of their services without the client's (or the client's legal representative's) written informed consent.

However, the ethics of the profession and the law allow for certain loopholes. Dr. Garber will alert you to these exceptions to confidentiality when you first meet together. As the client, you have a responsibility to remain informed and alert to these exceptions. They include:

• Safety always comes first. Dr. Garber will alert the police, child protective services or similar agencies any time he believes that an individual's safety is in danger. This includes instances of child abuse and neglect and threats of suicide and homicide.
  
• Dr. Garber's records are subject to demand under court order and subpoena. Although some such demands can and will be resisted, in general the court will receive records.
• Dr. Garber's records are subject to exposure under administrative review. Credentialing agencies can demand access to otherwise protected information.

In addition, the client (or the client's legal representative) can provide written informed consent allowing Dr. Garber to disclose otherwise confidential information to specific others and/or to obtain information from others.

Above and beyond these legalities, it is important to recognize the practical limitations of confidentiality in the digital age. These include:

• Electronic communications (e.g., email) and digitally stored records are vulnerable to exposure even when properly password protected, anonymized, firewalled and encrypted. Your choice to share confidential information in any digital medium constitutes tacit acknowledgement and acceptance of this risk.
• Digital payment media (e.g., PayPal, SquareUp) leave a trail that can lead to exposure of otherwise confidential information. Your choice to use these media constitutes tacit acknowledgement and acceptance of this risk.

  How is psychotherapy paid for?

• Clinical services are billed on the basis of a 50-minute hour. 
• Most psychotherapies are conducted for one 50-minute hour once per week, once every two weeks, or once per month. The recommended frequency of meetings will depend upon the urgency of the need.
• Payment is due in full at the time of service.
• Payment is accepted as cash, personal check, credit card, and via PayPal
  

  About insurance and insurance reimbursement

Dr. Garber will not bill your third party health insurance or managed care company. Payment is due in full at the time of service unless otherwise agreed in advance. Read more here

• Dr. Garber withdrew from participation with all third party (health insurance and managed care) payors in 1999 in the belief that such organizations needlessly compromise clients' autonomy and privacy. In addition, third party payors' expectations that an individual be identified as the "client" or "patient" and be diagnosed with a mental illness can create far more problems than they resolve. This is perhaps nowhere more true than when a child needs psychotherapeutic supports in order to manage his or her parents' conflicts.
• Dr. Garber will routinely provide you with a receipt for services provided including CPT service type, data identifying the client and data identifying his practice. Unless otherwise agreed in advance, the receipt will NOT include a diagnosis code.
  
• You are be free to submit receipts for psychological services rendered for third party reimbursement as you choose. Dr. Garber is glad to provide you with additional documentation in support of this choice at your request, but will not communicate directly with your third party payor.
  
• If you choose to submit claims for reimbursement, be a strong self-advocate: keep a thorough record of who you speak with, when, and what is said. Sadly, you must be very organized, assertive, persistent and expressive (and speak English) in order to succeed.

  Who is the "client" or "patient"?

The clinical client is the person or the people who are directly engaged in psychotherapy. The legal client is the person, persons, or agency that holds privilege, that is, decision-making authority over the process, e.g., whether to discontinue the therapy, to release the records, or to allow Dr. Garber to obtain information from others.

• Read more here

In most instances, when someone over 18 years of age engages in psychotherapy, he or she is both the clinical client (there in the room receiving services) and the legal client (able to make relevant decisions). The exceptions include adults who are court-ordered to psychotherapy and/or those who have a legal guardian.

In many instances, when someone under the age of 18 is in therapy, that person is the clinical client but his or her parents are jointly the legal clients. This distinction is most easily made when the child is quite young. Children ages 14 and older have certain protections which can trump even their parents' decisions.

When a child is the clinical client and his or her parents were never married, are conflicted, separated, divorcing or divorced, it becomes much more difficult to identify the legal client and who can make relevant decisions. In Dr. Garber's practice:

• Every effort will be made to assure that both parents are aware of, supportive of, and engaged in their child's psychotherapy.
• Although legally one parent's request to enroll a child in psychotherapy may be sufficient, Dr. Garber will make every effort to assure that both parents support the process from the start.
  
• Legally, if the parents share decision making authority in the eyes of the court, either parent's request to interrupt or terminate psychotherapy may be sufficient. In this instance, Dr. Garber will request an emergency parents' meeting and/or a final termination meeting with the child so as to minimize the child's experience of loss.
• Dr. Garber recognizes the practical, social and emotional role that parents' partners, extended family, and children's mentors (e.g., teachers, coaches, faith leaders) can play in a child's life and will often request that these caregivers contribute to the child's therapy.
  

 

  How does psychotherapy work?

A psychotherapist is a professional skilled in helping people to better understand their thoughts, feelings and relationships. Across types of therapy (e.g., cognitive, behavioral, dynamic, analytic), regardless of the professional's education (Ph.D. or Psy.D. or Ed.D., M.S.W.,  M.D., or LCMHC), psychotherapy is a process of facilitated change toward greater health, happiness and adaptation.

Psychotherapy works in three ways:

1. When the psychotherapist's non-judgmental, open and accepting attitude and the security of the setting invite trust, many people become able to express thoughts and feelings that they otherwise find threatening, unacceptable, or crazy. Anger or fear or guilt or grief. Jealousy or ambition or self-loathing. The professional's willingness to accept these expressions and to put them in a larger perspective can help to defuse or normalize them. The experience can be like setting down a burden that's been carried for decades.

2. The psychotherapist can also serve as a coach or mentor, to offer strategies and referrals to other resources that can help change troubling thoughts, feelings and behaviors. Familiar among these are journalling, role play, and imagery. Less familiar are techniques that include successive approximation, the use of transitional objects, and progressive muscle relaxation. Practiced in session and mastered as "homework," the psychotherapist can help you to build new skills with which to better cope with your world.

3. The psychotherapist is, at the very least, a "port in the storm," that is, a safe place outside of the real world pressures that can fuel overwhelming emotions. This is often the case, for example, when children shuttle back and forth between parents engaged in divorce wars. The children suffer the stresses of conflict, instability, and triangulation into the process. Child psychotherapy cannot resolve those pressures, but is often necessary to help the child keep his or her head above water until the adult conflict subsides.

Psychotherapy for children of divorce

Parents are supposed to anchor their children: To provide the safety and security necessary to refill their tiny gas tanks so that they can go off and meet the world, one step at a time. Dr. Garber has written about this back-and-forth dance of development poignantly in his book, "Holding Tight/Letting Go."

When parents conflict, the foundation of a child's security can be shaken or destroyed. The result can be seen in any number of ways -depression or rage, anxiety or regression, school failure, run-away, sexual or substance experimentation- but each of these can be reactions to the family turmoil.

Psychotherapy can provide a child whose emotional world has become a war zone a "port in the storm." The therapist and his or her office and that simple, single hour each week may be a child's most reliable, secure safe place while mom and dad fight it out. The therapist will help the child to express and understand his or her experience and emotions, will reassure that the parents' battles are not the child's fault, and that loving one parent is not a betrayal of the other. Most important to this therapy is its constancy as a "port in the storm."

• Psychotherapy with children whose parents are conflicted, separating, divorcing or divorced may be unique among the many kinds of psychotherapy. The child is the clinical client and may qualify for any number of mental health diagnoses, but he or she is a victim of an ongoing trauma.
• Legally, either parent may be able to enroll a child in psychotherapy. Dr. Garber takes the firm position that both parents must at least be aware of the child's proposed therapy from the start and -better yet- both parents should be involved in and supportive of that therapy. Read about "therapist alienation" at right.

How to get started? Dr. Garber will ask that the parent requesting services do so via email to Dr. Garber with a copy to the child's other parent. In this way, everyone can be on board simultaneously and the chance that Dr. Garber will be seen as biased or "on mom's side" can be minimized.

In fact, Dr, Garber is on the child's side.

Will the child's psychotherapy be drawn into the adults' legal battle? Dr. Garber will make every effort to assure that the child's therapy remains a "port in the storm," separate and insulated from the litigation.

In New Hampshire, case law may protect the child's psychotherapy from being drawn into divorce litigation.
Read more here

Can I see my record?

Dr. Garber keeps written and/or electronic records of all services provided consistent with relevant laws and ethics. Those files are maintained for seven years after the conclusion of the service (or longer when the clinical patient is ainor child) and then destroyed.

Relatively current files (that is, closed within the past year approximately) are maintained in a more accessible manner. Older files are archived.

In general, the legal client may be able to access the record of service or be provided with a written summary of that record, subject to a number of considerations:

• Any request to release the record of any service must be received in writing, signed and dated by a lgally entitled party.
• If your purpose requesting a record of service is to inform another, more current provider of the course of past treatment, it is usually far more efficient and less expensive to sign an informed consent allowing Dr. Garber to communicate directly to the new provider.
  
• Dr. Garber will not release a record in any instance in which he believes that doing so may cause harm.
• Release of records of court-related (forensic) services may be subject to court order
• Release of the records of a child's services may require the written consent of both parents.
• A fee may be required in advance of record release for retrieval, photocopying or scanning and delivery of the record. Additional charges may be associated with interpretation of handwriting, test data and other content.