Study on confidentiality in therapeutic settings (2023)

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The ethical code of the American Psychological Association plays an integral part in the psychologist’s professional duties. One of the most important of these codes is that of privacy and confidentiality (Standard 4.0). Confidentiality plays a crucial role in the psychologist/client relationship. Most clients view the psychologist as someone they can confide in. How can a psychologist avoid breaching confidentiality in both personal and professional settings? And when is it legally and ethically permissible to breach confidentiality? The author will explain the role that confidentiality plays in the psychologist’s profession, as well as discuss the limits of confidentiality, plus evaluate how this ethical code affects her ethical and personal decision making as a Psychosocial Rehabilitation Specialist.

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(Video) Introduction and Limits to Confidentiality

The ethics code applies to psychologists in every situation they may encounter; both at work plus in their personal and community affairs. The standards are enforceable, which means all psychologists should abide by them (Fisher, 2009). Psychologists should respect the dignity of clients they work with by ensuring they will protect confidential information (standard 4.01 Maintaining Confidentiality). Confidentiality can be described as the “cornerstone of professionalism” (Donner, Gonsiorek, VandeCreek, & Fisher, 2008, p. 369); and it is the primary obligation of a psychologist to protect their client information. The word “primary” comes from the Latin word that means first or most important; therefore, confidentially is the most important obligation of a psychologist (Donner et al, 2008).

It can be a problem if a psychologist discloses information that they should have kept confidential. There is a potential problem that could result in a law suit or negligence claim, or even having a professional complaint brought against them in an association they are a member of such as APA (Kampf, McSherry, Thomas, & Abrahams, 2008).

Fisher provided six steps for psychologists in protecting confidentiality rights, and to assist them in reclaiming themselves as experts to confidentiality. They are: provide a detailed explanation to the client about the role of confidentiality and the limits of it, be truthful and upfront, get informed consent, respond ethically to any request from the legal system, and avoid breaching confidentiality (2008). Some psychologists are not telling their clients about the limits of confidentiality, because they fear the client will react negatively and not open up if they know that everything they say or do is not kept confidential (Thelen & Rodriquez, 1994).

(Video) Explaining the Limits of Confidentiality to a Counseling Client

The Health Insurance Portability and Accountability Act (HIPPA) became law in1996, because of the increasing costs connected with transmitting health records across providers, institutions, and staff (Fisher, 2009). HIPAA requires “psychologists to take reasonable precautions to maintain confidentiality” (Fisher, 2008, p.131). In other words, they take the necessary steps to protect their client’s private information; especially when recording and transmitting information through e-mail, faxes, texting, and on the computer. When sending faxes and e-mails, a statement should be enclosed that the information is confidential. When personal information is stored on the computer, it is best to make sure it is password protected, where there they have to know the password in order to retrieve the information (Fisher, 2009). It is important, while using electronic methods of interacting with clients, to maintain their private health information; and to make certain that the client understands there can be possible risks to their privacy associated with communicating information through mediums such as: email, instant messaging, and phone conversations (Fisher, 2009). Psychologists need to protect their client’s information and private conversation; but when are there limits to standard 4 in the APA ethical codes?

Standard 4.02 explains how confidentiality of disclosed information has limits. Psychologists are under legal obligation to report child abuse and/or neglect. They must contact other professionals to protect a client from this abuse. For example, if they know a child is being sexually abused, they are required to call the Child Protection Services and police to protect the person from more harm (Principle A: Beneficence and Nonmaleficence). Additionally, psychologists are able to disclose confidential information if the disclosure is for a valid reason; such as threats of suicide or planning to hurt others (Fisher, 2009). Psychologists have a duty to warn a potential victim that their client has threatened some form of harm. It is misleading to a client if a psychologist doesn’t discuss standard 4.02 concerning the limits to the confidentiality contract. In other words, it is misleading if a psychologist does not tell the client that there are certain limitations to the things they are allowed to keep confidential (Fisher, 2009). It is important at the first session to tell the client that the things the psychologist tells them are confidential. However, if the client tells them they are suicidal, planning to harm someone else, or issues of child abuse, the psychologist is mandated to report it.

Standard 4.05 Disclosures deals with giving permissions. It allows psychologists to disclose confidential information when necessary, as long as consent has been obtained by the client (standard 4.05a). However, psychologists should decline the request for release of confidential information if they believe such a release will cause harm (principle A) to the client (Fisher, 2009). The client should provide authorization to what information is allowed to be shared; such as diagnosis, treatment plan, and other important information. Insurance companies are not allowed to require clients to sign over psychotherapy progress notes (Fisher 2009). The psychologist should avoid having clients sign blank consent forms to give confidential information to others organizations throughout a certain period of time; but they can sign a form giving a certain individual or organization information within the year (Fisher, 2009). Standard 4.05b allows psychologists to disclose confidential information without a consent: if the psychologist believes it is necessary, for incidents in providing services from the professional, obtaining consultations, protecting from harm, and in obtaining means to receive payment for rendered services The client should be notified of this as early as possible (Fisher, 2009).

Other situations that standard 4.05b to receive consent does not apply are: when the disclosure of information is mandated by the law, such as child abuse; suicidal tendency, and homicidal tendency. In also includes incidents as a duty to protect laws, such as preventing someone from spreading AIDS to another partner. If a student is planning school violence, the school is permitted to question the student and make sure they don’t have any access to weapons. Finally, psychologists don’t need a consent form signed when subpoenaed or court ordered (Fisher, 2009). Privileged and private communication in the position of a psychologist is private, but it is not considered privileged when it deals with the legal system. When a psychologist is subpoenaed to turn over documents, they can remind the judge of the confidential matter; the judge can deny the request for the psychologist to keep it confidential, and the psychologist would be required to disclose any request made concerning privileged communication (Fisher, 2009).

When a person threatens to harm or kill someone the duty to protect takes prevalence over confidentiality and as a legal obligation to disclose information when someone is dangerous, so that a safe resolution can be obtained. A psychologist can be held liable if something happened to the client and they did not disclose pertinent information, (Kampf, McSherry, Thomas, & Abrahams, 2008).

Other Cultures, such as in Australia, permit Psychologists to disclose confidential information when it relates to preventing harm or danger to others, suicide plans, abuse of a child, treasons or sabotage. However, it states they are permitted and it is not mandatory (Kampf, McSherry, Thomas, & Abrahams, 2008).

(Video) Confidentiality and Therapy

Confidentiality was the fourth most APA violation in the years 2004 through 2006. An author explains, “The centrality of confidentiality for the success of every psychotherapy relationship, explains how it differs from the legal concept of privilege, and highlights the multiple threats to confidentiality that exist” (Barnett, 2008. p.573). In other words, confidentiality is central to every psychologist/client relationship, and needs to be upheld at all costs.

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(Video) Confidentiality

Moral Principle is defined as” the principles of right and wrong that are accepted by an individual or a social group” (Dictionary on-line), such as the belief that people should not steal nor cheat; likewise, they should treat others with respect. People are taught throughout life to have common sense, based on a standard pattern of behavior that is considered normal in society; such as walking in another person’s shoes before you take sides, not judging a book by its cover, doing what you say you would, and telling the truth. Not only are these common sense beliefs, to direct us in our everyday actions, but there are also ethics that are in general held to be right. Most Psychologists abide by these values; not necessarily decided upon because of religion, but common sense of moral values when deciding ethical situations. Psychologists should use common sense in deciding and developing their own moral principles to help guide their behavior, and uphold ethical principles based on this (Perkins, 2004).

Every day the author, in her job, comes across ethical dilemma in regards to the issue of confidentiality; where she has to make decisions in handling them without violations of standard 4 Privacy and confidentiality (Fisher, 2009). As previously mentioned from classroom discussions, the author lives in a small town where everyone know everyone else, knows who is in trouble with the law, and knows what your profession is. It is a difficult situation when family members including nieces, nephews, cousins, etc know someone you are out in the community with, and will come up to you and start talking to your client, if they know them. In this situation, the author does not acknowledge the family member, and doesn’t tell the client that who she/he is talking to is a family member.

Family members have been told that in public places the author does not recognized them. If they come up to her, she will respond to them the same way she does to any other person that goes up to her and asks her a general question. One day the author kept this confidentiality rule when a family member was at the same park, who was swearing with other teenagers. The author did not say anything to the family member, at that time, while at the park. Along the same line, when picking a client up from school, someone the author knows will ask if they can get a ride home. and the author will say, “Not today, maybe tomorrow.” Another example of keeping confidentiality of clients in public is when someone asks who the child is that is with the author. They will be told, “A friend’s child;” if it is a teenager, the author will say, “A friend,” because she does not want them to be embarrassed, or to violate their confidentiality that they have a PSR. One school broke this confidentiality when the parent called the school to tell them that their teenager’s PSR would pick them up, and they announced it over the intercom as such. Needless to say, the client was mad; therefore, when the author calls the school, she will just say to tell the client that her ride is out front. This upholds the APA ethical code of confidentiality.

The author’s job requires progress notes to be computer generated. Therefore, she has to be careful and make sure progress notes do not get in the hands of those who are unauthorized to read them. The way to protect a client’s personal confidential information is: after typing the progress notes, the author will send them to her personal e-mail address, which no one has knowledge of the password. The author will go to the office, retrieve and print them, then erase the progress notes from her e-mail. She also makes sure that no one retrieves them from the printer. This has helped in not having the progress notes available for others to see in the car, in case of an accident. Likewise, the author has a password on her personal computer, which she uses to avoid any family member from seeing confidential information. As mentioned in discussion board in unit eight, the author makes sure, when she send e-mails about her clients to her boss or supervisor, that she includes this privacy note; “Contents in this e-mail may contain legally privileged and confidential information exempt or prohibited from disclosure under applicable law. If you feel you received this e-mail in error, please notify the sender, immediately delete the e-mail sent to you, and do not deliver, distribute, copy, or disclose its contents or take any action in reliance on the information it contains” (Progressive Behavior system).

There has been a time when the author had to call Child Protection Service because a client mentioned several times she wanted to kill her self; therefore, she had to have the parents take the client to the emergency room. It was the author’s legal obligation, according to standard 4.0?; which allows confidentiality to be broken when it is a duty to protect. The client was aware of this obligation that confidentiality does not apply when talking about suicide, and especially when she said it three or four times, that action had to be taken, and it was better to be safe then sorry (Fisher, 2009).

After taking PS502, the author realizes it is important to be careful in her actions, to maintain confidentiality of every client she works with as a Psychosocial Rehabilitation Specialist, and in her future as a Certified Drug and alcohol Counselor.

(Video) How to explain confidentiality to your client?

It is not just an ethical obligation to uphold confidentiality, but a moral obligation; not only for any psychologist but for those working in the field of psychology, such as: mental health counselors, PSR Specialists, and addiction counselors. According to the APA ethical code, confidentiality is important for any psychologist to uphold and abide by when working with clients. They need to get consent when confidentiality information needs to be shared with others; especially medical and therapeutic information, according to the HIPPA guidelines. In cases of child abuse, suicide and threats towards others, consent is not needed and the client needs to be aware of this. A Psychologist needs to make sure they do everything they can to uphold confidentiality when they are subpoenaed to turn over records. The author’s values are to do what is ethically and morally right, according to her personal belief; and to live with integrity when providing services to present and future clients.

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1. Community Forum: Special Services | January 18, 2023
(Council Rock School District)
2. Webinar: Protecting Confidentiality in School Based Health Settings
(School-Based Health Alliance)
3. Confidentiality
(Colorado Child Welfare Training System)
4. Counselling and Psychotherapy - Confidentiality
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5. Capital Health Ethics Support Privacy and Confidentiality
6. Counseling: Confidentiality
(Mometrix Academy)
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