It is essential that psychiatrists treat their patients’ communications as privileged. This means that patients alone retain the right to reveal information about themselves. The advent of managed care has raised even greater concern about the privacy of patients’ personal communications with their psychiatrists because of the potential for an increasing number of persons connected with the MCO to have access to material from patients’ files. Psychiatrists should caution their patient about the potential limitations to con-fidentiality and be prepared to explore the consequences of these exceptions. For example, if a patient is raising his/her mental health as an issue in litigation, some or all communications to a psychiatrist could be legally discoverable. Coherent boundaries with regard to confidentiality send the message to the patient:
My thoughts and feelings belong to me. The doctor does not treat them as if they belong to him/her.
Indicated means of preserving confidentiality include obtaining proper authorization from patients before releasing information, explaining the need for confidentiality with parents of children and adolescents, and involving all participants in fam-ily and group psychotherapy in agreements about confidentiality. Problematic activities that may endanger confidentiality include stray communications with concerned relatives of patients in individual psychotherapy, where there is no prior expectation on the patient’s part about discussions with relatives; discussion of privileged information with the psychiatrist’s own family mem-bers; releasing information about deceased patients; and failure to properly disguise case presentations.