St. Export is the fictional name of the small town where I have practiced psychotherapy for eighteen years (but do not live). Small towns may be seen as quaint, secure, supportive and self-sustaining or narrow minded, xenophobic, suffocating and predictable. Whichever perspective applies, the therapist must grapple with ethical challenges relating to the size of the community, especially privacy and anonymity.

The Patient's Privacy

Anna, a woman in her 50’s, was in a long-term therapy group of mine. Though I had never met her before she began attending the group, it soon became clear that I knew her uncle and aunt, her niece and the niece’s husband. I also banked where her best friend worked and knew another close friend and her husband. I treated her cousin and his son, a teenage friend of her daughter’s and this young woman’s mother, a neighbor from across the street, and the daughter of a neighbor’s girlfriend who was the daughter of a local merchant to whom I had been introduced by Anna’s uncle. I served on civic boards with an old boyfriend of Anna’s as well as a cousin’s husband, and had met her three brothers at social functions. In the course of treatment, I consulted with her two daughters and the boyfriend of Anna’s boyfriend’s daughter. The only people who knew I was Anna’s therapist were her daughters. As I recount this web of connections I almost get dizzy.

While I struggled to protect Anna’s privacy, I came to understand that for Anna my knowing her world and the players in it outweighed the issue of her privacy. In fact, she expressed relief that I was familiar with the people she discussed in therapy. It was as if my knowledge gave her experience in therapy greater validity.

The Therapist's Privacy

After eight years of practicing in St. Export, I became engaged. I did not place an announcement in the town paper nor in my hometown paper and decided, after much consultation with colleagues, to wait to disclose my engagement to patients. To my surprise, when I brought it up a few months before the date of the wedding, I found that most of my patients were already aware of it. The information had been passed on among members of my three psychotherapy groups with an agreement, tacit or otherwise, to keep my secret a secret. I was part of their small town, and they did what they do to protect privacy–they waited for me to tell them.

Our ethical codes require us to provide as much anonymity as possible. But in small towns this is not always possible or is managed in a different way. Did Anna wish for more privacy or had she accepted that it was unrealistic? Just as I strived to be "naive" about her many "connections," Anna’s relatives and friends never acknowledged they knew that she was in treatment with me. It was as if we all agreed to create privacy for her just as my patients had done for me.

Providing treatment to those in need is a primary social work value. In a small town this may mean accepting referrals even though there may be overlapping relationships which present a major challenge for the practitioner. What first appears to be an obstacle, however, can lead to the development of flexibility, creativity and an ethical attitude. At the very least, practicing in a small town is far from boring,

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Mario Starc, M.S.W., is a student at CICSW and in private practice in Tracy and Berkeley.

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