Everybody gets a HIPAA violation
Season 1, Episode 1
Rachel breaks confidentiality for ALL of her clients on her very first day of internship. She mitigates the fallout with the support of her site supervisor, only to feel shamed by a professor while presenting the situation at a case conference.
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Episode Transcript - Everybody gets a HIPAA violation
Katherine Esquer
Hey, Allie when's the last time you broke? HIPAA?
Allie Joy
I don't think I ever have. How about you?
Katherine Esquer
Never? Well, it makes me feel kind of bad. So, you know, I actually had a situation happen earlier last month, where a client of mine was given the appointment summary sheet for a different client. So obviously, that is completely violating HIPAA, and we had to go through a whole set of procedures. But it's something that happens, you know, in our fields from time to time. And I can't wait to talk to Rachel about her experiences.
Allie Joy
Yes. And I will say it does happen. I feel like I've just gotten lucky so far. But it could happen for me in the future. No doubt about that. But today, we are going to talk to Rachel, who, on her very first day of internship, broke HIPAA and had violations with all of her clients. And again, this was on her first day of her internship. So we're going to hear about how that felt for her.
Katherine Esquer
Yeah, I think she absolutely has maybe all of our clients at once that, that has to be record there. But before we get into it, this is a friendly reminder that everything we say here is for entertainment purposes. And it is not a substitute for therapy, ethical guidance, or clinical consultations.
Allie Joy
All right. Well, this is episode number one of am I a bad therapist. Let's get into it. Hi, Rachel, before we hear about why you're a bad therapist, why don't you tell us a little bit about yourself and your clinical practice?
Rachel Elder
Yeah, thanks for having me on. I'm Rachel Elder. I am a couples therapist in Seattle, Washington. I'm also a relationship coach. And so I do both businesses just trying to help build stronger relationships. And I have been doing this for five years now. Not strictly in couples. But you know, I've had quite the experience of trying a bunch of niches and finally narrowing down that this is the work that I love to do. But I think as of this year, as of next month, it'll be five years of being a therapist, which went way faster than I could have imagined.
Katherine Esquer
Time flies when you're having fun. So, five years of clinical decision making and navigating the gray areas. I'm sure you have lots of stories to tell us. But to start off with, what is the one story you want to share with us today on why you're a bad therapist?
Rachel Elder
Yeah, I'm gonna tell my first day of internship where I violated HIPAA with my first client ever.
Katherine Esquer
Well, you can only go up from there in your career. Gotta get out of the way. You violated HIPAA at your first day of internship with your first client ever. All right, let's hear it.
Rachel Elder
Yeah. So I did my internship at a community mental health agency, and I was primarily going into schools, working with elementary, middle school and high school, but this was a high school that I was going into, and I went with my agency supervisor who was also seeing adolescents at the high school and she was just showing me some of the clients from her caseload that she was going to be handing off to me for my internship here with the agency. And we were just doing an introduction session with a client just so they could meet me and do that gentle handoff that doesn't always happen but was happening, which was great. And the client was like, and who else are you going to be seeing at the school. And I was so nervous, so anxious, I wanted to make that first good impression and show that I'm competent and qualified. And I just answered, I didn't think about what her question was asking or what their question was asking. I just answered and listed off the names of the clients I knew I was going to be seeing at the school.
Katherine Esquer
So you not just broke HIPAA for one patient? You broke HIPAA for lots of patients.
Rachel Elder
Yep. Every every client that was going to be on my caseload at that time at that school. Yeah. So in the moment, I had no idea what I had just done. And so we, we wrapped up the introduction with the client. And my sweet, I chose this, this internship site because of the supervisor hoping that she would be mine. So sweet, so gentle, and says, Hey, I just want you to know, that's a violation of HIPAA. You can't tell clients who you're seeing, it's up to them if they talk about it, but you can't do that. And, gosh, I wish I could remember, I probably had like an instant face of like whiteness, and like, what did I just do? But she was so gracious. She's like, you know, like, these things happen. And we can talk about how to navigate it. And I think the decision at that time was that, you know, I would have to let clients know, I had violated HIPAA, and that I was willing to kind of take ownership and any action that they would want to feel comfortable. And all the clients were super cool. They're like, oh, we all talk about who we see, like, that's just how the school works. So we all know that you're seeing us like, we're all friends, we all talk about it. We know that already. So that was really nice and felt very gracious and compassionate and helped me in that moment be like, okay, like, I'm not a terrible person. I can, I can recover, I can repair with clients, no big deal. It was actually a month later, that I really felt the weight and impact of the action I had done with violating HIPAA. We had practicum facilitators through our school where we brought in case studies. And so I brought in the case study with this client who I had disclosed the information to and that first session, and didn't think my case study was really focused on that it was I can't even remember, I don't remember what it was, but something about the relationship dynamic with me and this client and trying to get some kind of case consultation around it. And my supervisor, who is the teacher for that class, also happened to be our professional ethics teacher for our school, and instantly stopped me and said, do you understand what you did? Do you understand how severe that is? And that there are all these actions you now need to take. And I remember sitting in the class in front of my peers, like 10 other peers and thinking, oh, my gosh, no, I, I don't think I realized how severe it was because of how the agency navigated it with me. But now I had this teacher pretty much putting the fear of God in me of, are you really cut out for this work? And I remember leaving class and just crying and feeling so much shame. And really feeling like, can I really do this? I've spent four years to get to this point. And now I'm wondering, is this the right path for me? And will I even be able to get to that goal of graduating and doing this work? Because I violated HIPAA. Now, am I out of the game? Is this all over for me?
Allie Joy
Oh, man, yeah, that's so interesting how the agency and your professor handled it so differently. That part really stands out to me. Like you said, it was a month later that you had you kind of processed it, were dealing with it. And then it's like this even bigger kind of bomb dropped of like, oh my gosh.
Katherine Esquer
Also did it feel like a personal attack as a as opposed to, you know, acknowledging the situational aspects involved.
Rachel Elder
I think that did come up for me like it took me I feel like it took me a month after that to like process through the shame. Like my classmates were also kind of you honestly, like it wasn't out of ill intention. You weren't trying to cause harm. It was an honest mistake that any of us could have made like that's the whole point of practicum is to learn how to do this and you made a mistake. And so sometimes I wondered if it was just more of how the teacher handled ethics and just like law and the ethics teacher, so I should kind of have the like the strong reaction and tell you how bad this is. And that was really the only person who spiked that shame within me. And everyone else around me, my agency, my supervisor at the agency, my classmates were all like, this is just really hard. And you didn't have to bring this in like you, you didn't have to add that to your case consultation. And you did. And now you're dealing with the shame instead of actually having the valuable case consultation that you were seeking and needing to do good work with this client. So it did feel like, it felt a little personal. I don't know why it would be like it didn't really have anything with this teacher. But it really the focus then became all of the wrong I had done. Versus holding. I know and I know, I can't be the only therapist in their career. I know I'm not. And so instead of like walking through the steps, like when this happens, here's the things we need to do and, and have in place to kind of repair and fix the situation. It was just more of this focus of like, you're a bad therapist, even though those weren't the words, that was the impact with her reaction towards what had happened.
Katherine Esquer
And I can imagine your biggest fear was, am I a bad therapist? Can I like you said, can I cut it in this field?
Rachel Elder
Yeah, I think it's interesting. I mean, I went to that place of like, so am I out? Like out? Does this eliminate me from becoming a therapist? Like, did I just make the biggest violation that I can't actually do this work now? Which is interesting every time the stories I have of am I a bad therapist, that's what comes up with like, Am I out of the game now? Like, I can't do this anymore? Did this just rule me out of all this hard work that now I can't continue on with something that I've been pursuing for so long?
Katherine Esquer
Well, before we get into the rollout, or the outcomes of what happened after your teacher really identified the major, major flaw or the major ethical violation in the releasing of HIPAA protected information, what would you say was your gut response sitting in that classroom?
Rachel Elder
I think shame. I am a crier. So I probably cried. As she was responding to me, but I just remembered the shame. And battling that shame for weeks. Just trying to navigate like, like, am I a bad therapist? Is that really true? I keep saying am I not cut out for this? I, if I couldn't remember this one huge ethic? Am I really cut out? What about all the lists of pages of ethics, we have to remember, if I violated one of the most major ones, maybe I shouldn't be doing this work?
Allie Joy
And did you end up talking to your supervisor about this at all, like your professors response? Or how did you kind of try to process your professors response.
Rachel Elder
I definitely processed it with my peers, I was lucky of like my I called it like my grad school bestie like we were in all our classes together. And I remember got to talking with her a lot of you know, just trying to process the shame I was feeling. And it's hard to remember now, so much has happened in five years. I do remember following up in class, and I remember crying in class just talking about the shame and how difficult it was to receive her reaction. And trying to understand what I needed to gain from it, but also not feeling like I was supported as a supervisor for the practicum experience. And I really wish I could remember what happened. I mean, I made it through practicum I you know, I didn't quit I wasn't ruled out. And I want to, maybe this was my idea, I want to believe like she was able to respond more kindly and talk about it a little bit more. But I think I what I remember most is my peers, just saying like, yeah, that shame would be real. And of course, you would feel that way. And it's helpful for us to actually hear this story of how easy it can be to do this without recognizing and how much we are trying to develop our mindset as therapists how we show up as a therapist, and also all these behind the scenes parts of our code of ethics, and the responsibilities at this agency setting on top of the responsibilities of our school, for internship experience, and that it's just a lot to manage on top of your personal life as well. And the expectation to still write your papers and do your homework assignments and your readings while working for free for almost, it felt like full time, it was probably more part time. But just trying to manage it all. I think what helped me through some of that shame was that my my peers were like thank you for sharing the story. And thank you for allowing us to witness that so we can learn from it, versus it being kind of put in this frame of you're a bad therapist, and here's why. And we will always remember you as a bad therapist.
Katherine Esquer
It sounds like you had such an amazing cohort to go through school with and I can personally relate, there is no better place to have a personal crisis or an existential crisis or professional crisis, any type of crises, than in graduate school for mental health, like it is so supportive the cohorts are, I mean, I know not everyone has had that experience. But my experience as well has been, it's a really great place to be able to stretch our vulnerabilities, stretch our tolerance of vulnerabilities, stretch introspection, and really, like, look inward and and have that support around us. So I'm glad you I'm so glad you had that experience with your cohort. Oh, my goodness.
Rachel Elder
Yeah, it was it. It was a good, good class practicum. Not all of them were like that through the four years, but that one I was really thankful.
Katherine Esquer
Yeah, so my biggest burning question here is what was so different between how your site supervisor told you how to handle it and your practicum slash ethics supervisor told you how to handle it. Why were they so mismatched?
Rachel Elder
I mean, when I think back to it, my guess is that the agency, they've just probably seen more more violations of HIPAA or the code of ethics, like learning them, applying them that there's just in a community mental health agency setting the- yes, there are regulations, but I think there is more creativity of how we go about it, like I met clients out in public, like we really focused on like meeting clients where they were at, you know, I had sessions in a Starbucks, making it very clear, like, there's not confidentiality and privacy here. Are you comfortable going into this and clients been like, yeah, because that was the only way for them to get to their session, they couldn't always get to the office, or they didn't have parents supporting their decision. So we, we met in a place that they could, could be seen, and they were able to have that support. So I think the agency setting just had really embraced like, as long as we are talking about the boundaries, making sure it's informed consent, that, that was really what mattered. And helping clients understand privacy and confidentiality, versus my school setting was really about, I mean, their role was to kind of drill this into us, these are the code of ethics, these are the things you need to be aware of. And maybe it was just my school and how they taught that like I remember taking professional ethics a summer before internship and thinking, if I would have taken this the first year of grad school, I probably would not have finished the program because it really put the fear of God in you of like, if you do these things, you will lose it all. And maybe there's an intentionality of like trying to show like how important it is to respect and honor these codes and not take them for granted. But I just, that was my experience of these code of ethics are so important, do not make mistakes, do not break them. Or you might find yourself in court, you might find your license being revoked. So I think maybe that's the difference. So that was her role in the school was to teach that class, and then her role in our practicum to make sure we are hitting the benchmarks or the things that we need to be heading to become graduates of a counseling program. And the agency setting, you know, they brought in interns every year from different schools, and those interns left every year. And so maybe understanding the ebb and flow of therapists of developing their identity, developing their sense of self, as I sit across from people who are going through trauma, mental health concerns and understanding that there is more grace and growth that's maybe needed in the process. So I don't know if that was the difference and maybe just the different kind of modalities taught to you. Versus the agency was more of the evidence based practices. My school is more of this narrative, psychodynamic, relational. And so I sometimes wonder if that played into it as well. But the agency was definitely way more laid back about it than my school.
Allie Joy
And did you end up having to go back like after the strong reaction from your practicum supervisor? Did you have to go back and do anything additional at your site? Or did you just kind of leave it how you did with already informing them, you know, the month prior with how you kind of like decided how to handle it with the agency?
Rachel Elder
Yeah, my practicum teacher was like, you need to go back to the agency, they need to understand what happened. Not just your practicum supervisor at the agency, but the program director at the agency needs to know. And you need to ask like, what are the steps you need to do to make this right? And so I went to my agency supervisor, totally crying. I'm like, my teacher says, I need to do this. What do I do? Do I need to do these things? And she was like, why don't we go talk together like it's okay. And we went and talked with my program director. And both of them were graduates of the school, I went to, so I think that helped, too. And he, I remember, he was just like, you've done everything you need to do. Like, if the client was like, I feel very violated, I would like these steps to be taken, that would be different. But you've, you took ownership with your clients, you were direct with them, you named what happened, they all reflected that they were okay. If they would have said that they weren't okay, then we would have taken some different steps. But you've done everything you need to do like, we don't need to report this to the board. We've taken the steps that are needed. And so I can't remember, I think I took it back to my practicum and kind of said that these were, this is where the agency stood. And I think my practicum teacher just supported that. But it was it was still the same reaction of you 've really done everything you can like, it's okay, you're gonna make mistakes, which is so nice, but also just the battling of like, but can I trust that? Like, are you sure there's not these additional steps? I don't need to contact the board and let them know I did this on my first day of practicum. And what should I do? Should I should I get a degree? It was just these it was very different worlds to be in with the class and then actually, in the agency setting doing the work.
Katherine Esquer
Oh, I think I think all of us in the fields can relate to what we learned in the classroom versus how it looks out in the field. And I think this is a great example of a pretty big HIPAA violation, what it looks like in the classroom versus what it actually looks like in the field and, and how it practically can play out right, where all parties are satisfied and covered. And yeah, this was a great example. And I can see why when we asked you to join us on the podcast called am I a bad therapist, your brain immediately went to this story.
Rachel Elder
Yeah, I have two that always come to mind this one and another one. And this one is definitely the biggest, of you broke HIPA. Are you cut out to do this work is that's like the theme when I think back to the story of what I went through.
Allie Joy
Yeah, I mean, it is a great story. But it's great to talk about too, because it does happen. I think that highlights it so well. And if anything, I feel like it's interesting with the practicum supervisors response, like I understand HIPAA is a huge deal. It is, of course, but I feel like internship and practicum, that's the place to make mistakes at the same time. Like, you know, we learn all these theories and all these great things. But when we go into the place to practice it, we're like, what did I learn anything? I don't know how to do this. So we have to grow. And we have to make mistakes. And I understand the severity of it. But it's interesting, you know, making you have so much shame as a response. I feel like I would feel the same way.
Rachel Elder
Yeah, it's interesting to me, because you know, I have a private practice. So it's a business. And my husband has a business too. And I think about how companies like they get, what's the word? Oh, gosh, I'm gonna fail. Now them on the spot, like information gets leaked all the time, right, their security, their security breach, that's what it is, as their security practices get breached, and then that information goes public. And that that happens almost daily. And people don't have that same response. And yet, here we are, as therapists granted, these are different fields. But it's like, oh, there's been a security breach. And that instant thought is like, am I out of it? Like, does this, am I qualified to do this work? Should I be doing this work? There's more of this personal hit that happens versus these businesses dealing with this every day. They're like, oh, we just send the letter out. And people let us know if they want us to do anything about it. And we go on with our life versus us as therapists is like, my world is ending. Can I really do this? Am I, should I be doing this? That I feel like there's more shame. It's just always interesting for me comparing just these business worlds of here we are in business. Here, other people are in business. And it's just so different. And trying to explain that to people like we are in a profession that has this code of ethics that is very gray. And it's created for a reason. But then it also creates a lot of that fear of am I doing the right thing? Is this the right decision to do? How do I navigate this and we are kind of being kind of thrown in there to figure it out on our own. Luckily, we have wonderful colleagues and consult groups and supervisors. It's just such a different world sometimes, and trying to explain it to people, they're like, wait, what? I have to do why? That's like, yeah, yeah, if you see me in public, I'm gonna pretend like I don't know you unless you come up to me and don't take it personally, that's just me following these code of ethics that I have to live by. People just don't get it.
Katherine Esquer
That gray! Yeah, I think we as therapists are faced so much with that gray. And that's why Allie and I wanted to start this podcast because we are humans who use our humaneness for our work, right with, we have to abide by code of ethics, but it's also gray and murky, and so much comes up. Maybe not as much comes up for me on a daily basis as it did for you on your first day of internship. But, so Rachel what, if there was another student who was in your shoes, you know, in a graduate program just made a horrible breach...I shouldn't say horrible, that's a judgment call. Definitely not horrible. But a large breach of HIPAA. On their first day in the clinical field, what would you tell them? What would you say to them?
Rachel Elder
I think I would say feel the emotions you're feeling, create space to feel them, don't, don't try to react right now. Just experience what you're feeling. And then reflect on what you feel like are the next right steps to do to kind of honor those code of ethics or honor, what you feel like is the right step for dealing with this, and then turn to the people you feel like you also are going to give you that valuable kind of consultation or consideration of steps to do as well. I think and that reminder of give yourself grace and compassion, you are a human being in this, you're doing your best, most likely. And if you're not, then we need to have a different conversation. But you are doing your best. If the intention wasn't to cause harm, that's a good stepping stone. Let's explore what happened, how you can learn from it, you're meant to grow, you're meant to be able to figure out how to develop who you are as a therapist, your sense of self in the room, and trying to understand how to honor these code of ethics at the same time as attending to your clients and where they're at and holding the stories that they have.
Allie Joy
Definitely, I actually I have a follow up question. I'm curious, because a lot of us are now in our career supervisors, some of us are educators. Is there anything that you wish your practicum supervisor would have done differently in responding? Like, how do you feel like if you could give feedback? How would you want a supervisor or professor to respond to a situation like this?
Rachel Elder
I mean, always, you know, like putting yourself in the other person's shoes. So I feel like she really did respond in teacher mode, which is her role, right? But I really wish you would have slowed down and said, okay, I'm gonna imagine what it's like to be an intern, again, starting new in this field, not fully understanding all the concepts and all the things. How are you feeling? What do you need to know? And how can I actually guide you and provide that facilitation that we need in this classroom versus kind of attacking? It wasn't an attack, but it felt like an attack because it pulled up shame for me, versus like, harping on, you made a mistake. And it's a serious mistake. And you need to know that it's a serious mistake. I feel like I got like the punishment from a parent versus okay, let me help you understand what happened and what this means. And then we're going to talk about some options of how we navigate this. So you can repair the situation or yeah, repair the situation and take the the appropriate action steps, versus just having that shame. And I don't know if that was all in her. I just remember the shame. And that might have been more of my story. But I definitely, her reaction was way different than the agency supervisors reaction.
Allie Joy
Yeah, well, I think it can be a good reminder of like, even when we are more seasoned or you know, we feel more familiar in our roles. I think it is good and important to have that compassion, especially with interns, or supervisees, or things like that. And that's why I feel the same way. I wish there would be a little more compassion or understanding, I think that can be really valuable. And make you feel a little more supported and not so shamed.
Rachel Elder
Yeah. I'm a supervisor now. And it's, the story is so helpful in my work now, I'm just like, hey, if I have gone from that to this, we're going to help you navigate the mistakes that come up and how to approach it in the most professional, ethical way. Let's slow it down. We need to understand how you're feeling first, and then we can talk about out how to repair and mend what has happened and talk about the ethical pieces that come up feels like the whole importance of supervision. And yet in my experience it, it didn't get to be like that, at least in the classroom setting.
Katherine Esquer
Mistakes are gonna happen, right?
Allie Joy
Awesome. Well, thank you so much for sharing with us. It was so great to hear your story, hear what made you feel like you are a bad therapist and give us good reflection on again, those feelings of shame, HIPAA violations. And just thank you so much for sharing.
Rachel Elder
Yeah, thanks for having me on.
Katherine Esquer
So Rachel, if people want to connect with you, after listening to this podcast, where can they find you?
Rachel Elder
I am on Instagram. It's Rachel elder coaching. So I show up there and share a lot of relationship tips and ways to build your relationship stronger. But I'm always open to DMS and connecting and whether it's therapy wise, business wise, I love the networking side of all of this. So that leads to incredible opportunities like being on podcasts.
Katherine Esquer
Thanks, Rachel.
Allie Joy
Thank you so much!
