A Request to Withhold Information from a Client

This requires separating what I can and cannot promise.

What I cannot promise: I cannot agree to omit clinically significant information from the shared health record or conceal it from the treating GP. Alcohol intake at this level, cessation of metformin, and a raised ALT are directly relevant to his diabetes management, his medication safety, and his liver health. Concealing them could contribute to harm - for example, if the GP restarts or adjusts metformin without knowing his drinking pattern, or attributes deteriorating glycaemic control to diet alone. I would explain this honestly and without judgement, rather than agreeing and then breaching his trust.

What I can do: I can be transparent about how information is shared and give him control over the process. I would offer to write the note with him present, explaining what I am recording and why, and offer that we contact the GP together or that he tells the GP himself with my support. I can also be explicit about what I will say - for example, that I will describe his alcohol intake and his reasons for stopping metformin, and that I will recommend a non-judgemental conversation about options.

Documentation: I would record the alcohol history, the metformin cessation, his disclosure and his request, my response, and the plan. Recording his request for confidentiality is itself important - it shows I took it seriously and explains the context. I would not record speculative judgements about his drinking, only what he told me and what I advised.

The professional reasoning is that trust and safety are not in opposition here: the way to preserve the therapeutic relationship is honesty about limits plus genuine partnership in how the information is shared.

His statement tells me the barrier is not knowledge but previous experience of shame. A lecturing, directive style predictably produces disengagement in someone who has already avoided care for a year. I would use a collaborative, autonomy-supportive approach:

• Ask permission before advising: 'Would it be alright if I shared what I know about alcohol and metformin?' This preserves his sense of control.
• Explore his reasoning without correcting it immediately: he believes metformin and beer do not mix. There is a real clinical concern behind this - metformin is associated with lactic acidosis in the setting of significant liver disease or heavy alcohol use, and his ALT is raised. So his instinct is not foolish, even if stopping the medication unilaterally without alternatives is risky. I would acknowledge that and then explore options with his GP, such as reviewing the medication rather than simply resuming or abandoning it.
• Use reflective listening and avoid confrontation: 'It sounds like last time felt like being told off, and that made it easier to stay away.' Naming the experience often reduces defensiveness.
• Focus on his goals, not the behaviour: ask what matters to him - energy, avoiding complications, being around for family - and link the conversation to that rather than to units of alcohol.
• Offer choice and a clear next step: for example, agreeing on a review appointment with the GP where the focus is medication options, and a separate conversation about alcohol when he is ready, with harm-reduction framing rather than an abstinence-only demand.

I would also ensure he leaves with a concrete plan and a sense that returning is worthwhile, since re-engagement is the immediate clinical priority.