duncan et al 2015 ethical dilemmas of confidentiality with adolescent clients case studies from...

8/18/2019 Duncan Et Al 2015 Ethical Dilemmas of Confidentiality With Adolescent Clients Case Studies From Psychologists

1/26

Full Terms & Conditions of access and use can be found athttp://www.tandfonline.com/action/journalInformation?journalCode=hebh20

Download by: [b-on: Biblioteca do conhecimento online UAC] Date: 12 April 2016, At: 08:33

Ethics & Behavior

ISSN: 1050-8422 (Print) 1532-7019 (Online) Journal homepage: http://www.tandfonline.com/loi/hebh20

Ethical Dilemmas of Confidentiality WithAdolescent Clients: Case Studies FromPsychologists

Rony E. Duncan, Annette C. Hall & Ann Knowles

To cite this article: Rony E. Duncan, Annette C. Hall & Ann Knowles (2015) Ethical Dilemmas of

Confidentiality With Adolescent Clients: Case Studies From Psychologists, Ethics & Behavior,25:3, 197-221, DOI: 10.1080/10508422.2014.923314

To link to this article: http://dx.doi.org/10.1080/10508422.2014.923314

Accepted author version posted online: 11 Jun 2014.Published online: 25 Sep 2014.

Submit your article to this journal

Article views: 1230

View related articles

View Crossmark data

http://crossmark.crossref.org/dialog/?doi=10.1080/10508422.2014.923314&domain=pdf&date_stamp=2014-06-11http://crossmark.crossref.org/dialog/?doi=10.1080/10508422.2014.923314&domain=pdf&date_stamp=2014-06-11http://www.tandfonline.com/doi/mlt/10.1080/10508422.2014.923314http://www.tandfonline.com/doi/mlt/10.1080/10508422.2014.923314http://www.tandfonline.com/action/authorSubmission?journalCode=hebh20&page=instructionshttp://www.tandfonline.com/action/authorSubmission?journalCode=hebh20&page=instructionshttp://dx.doi.org/10.1080/10508422.2014.923314http://www.tandfonline.com/action/showCitFormats?doi=10.1080/10508422.2014.923314http://www.tandfonline.com/loi/hebh20http://www.tandfonline.com/action/journalInformation?journalCode=hebh20


2/26

ETHICS & BEHAVIOR, 25(3), 197–221

Copyright © 2015 Taylor & Francis Group, LLC

ISSN: 1050-8422 print / 1532-7019 online

DOI: 10.1080/10508422.2014.923314

Ethical Dilemmas of Confidentiality With AdolescentClients: Case Studies From Psychologists

Rony E. Duncan

Centre for Adolescent Health

Murdoch Childrens Research Institute, Royal Children’s Hospital

Department of Paediatrics

The University of Melbourne

Annette C. Hall

Centre for Adolescent Health

Murdoch Childrens Research Institute, Royal Children’s Hospital

Ann Knowles

Department of Psychological Science

Swinburne University of Technology

Navigating limits to confidentiality with adolescent clients can be ethically and professionally

challenging. This study follows on from a previous quantitative survey of psychologists about con-

fidentiality dilemmas with adolescents. The current study used qualitative methods to explore such

dilemmas in greater depth. Twenty Australian psychologists were interviewed and asked to describe

an ethically challenging past case. Cases were then used to facilitate discussion about the decision–

making process and outcomes. Interviews were transcribed and analyzed using interpretive content

and thematic analysis. Three key findings are discussed. First, it is of little use to perceive confiden-

tiality dilemmas as binary choices (breach/don’t breach) because psychologists described 5 distinct

options. These can be conceptualized on a spectrum of varying degrees of client autonomy, rang-

ing from “no disclosure” (highest client autonomy) to “disclosure without the client’s knowledge or

consent” (lowest client autonomy). Second, confidentiality dilemmas often involve balancing multi-

ple and conflicting risks regarding both immediate and future harm. Third, a range of strategies areemployed by psychologists to minimize potential harms when disclosing information. These are pri-

marily aimed at maintaining the therapeutic relationship and empowering clients. These findings and

the case studies described provide a valuable resource for teaching and professional development.

Keywords: adolescent, ethics, confidentiality, minors, privacy, parents, psychology, psychiatry

Correspondence should be addressed to Ann Knowles, Associate Professor, School of Health Sciences, Swinburne

University of Technology, John Street, Hawthorn, Victoria, 3122 Australia. E-mail: [email protected]

mailto:[email protected]:[email protected]


3/26

198 DUNCAN, HALL, KNOWLES

Jay Giedd (2008), a psychiatrist and international expert in the field of neuroimaging, has

described adolescence as “a time of great risk and great opportunity” (p. 341). Adolescents dif-

fer from both children and adults in their physical, psychological, and social functioning. Theyhave distinct capacities, priorities, and previous life experiences and as a consequence of this

they require a unique therapeutic approach. Working with adolescents in a psychological setting

holds significant potential for impacting positively on their psychosocial trajectory in an endur-

ing way. However, the high potential for risk that also accompanies this life stage increases the

complexity of psychological work considerably. This is particularly true in relation to the ethical

principle of confidentiality. The current study follows on from a previous quantitative survey of

Australian psychologists about confidentiality dilemmas with adolescent clients. The purpose of

the current study was to use qualitative methodology to explore these ethical dilemmas in greater

detail.

The principle of confidentiality might initially appear relatively simple. Maintaining confiden-tiality is well established as a key component of effective psychological care; vital for sustaining

trust and a strong therapeutic alliance (Gustafson, 1997; Isaacs & Stone, 1999; Kobocow,

McGuire, & Blau, 1983; McCurdy & Murray, 2003; Sealander, Schwiebert, Oren, & Weekley,

1999; Sharkin, 1995). Professional codes of ethics are also explicit about the importance of con-

fidentiality, listing only a small number of specific circumstances in which confidentiality may be

breached (American Psychological Association, 2010; Australian Psychological Society [APS],

2007; British Psychological Society, 2009). The APS (2007) describes four distinct conditions

under which it is appropriate for psychologists to “disclose confidential information obtained

in the course of their provision of psychological services” (p. 15): (a) when the client (or legal

proxy) provides consent, (b) when there is a legal obligation to do so, (c) when there is “an imme-

diate and specified risk of harm to an identifiable person or persons” (p. 15) that can be avertedonly through disclosure, and (d) when consulting with colleagues or in the course of professional

supervision. However, despite the consistency of current guidance, previous research indicates

that psychologists are challenged by the practice of confidentiality (Kampf, McSherry, Thomas,

& Abrahams, 2008; Younggren & Harris, 2008), suggesting that managing confidentiality is far

from simple.

The APS has also developed a set of guidelines specifically about working with young people.

These guidelines reiterate the limits to confidentiality contained within the APS code of ethics

and emphasize that a psychologist has a duty to maintain a young person’s confidentiality and

to limit any disclosure in accordance with the express wishes of the young person, unless there

is a clear risk to the young person or to others (APS, 2014). The guidelines also note that when

involved in decisions about whether to disclose a young person’s information, the young person’s

best interests should be paramount and the young person’s wishes should be respected where

possible.

All Australian states provide for confidential and anonymous reporting of suspected child

neglect and abuse where there are reasonable grounds for this belief. However, registered psy-

chologists are not legally mandated to report child abuse in all states. The Australian ethics code

requires psychologists to be aware of legal and organizational requirements for reporting child

abuse and requires that wherever possible clients are informed of the psychologist’s legal and

organizational obligations.


4/26

ETHICAL DILEMMAS OF CONFIDENTIALITY 199

ADOLESCENT DEVELOPMENT

Globally, the life phase of adolescence is gaining increasing recognition as a pivotal stage inthe biological, psychological and social development of individuals. In 1968 the Society for

Adolescent Health and Medicine was founded, and today this society comprises an international

membership (http://www.adolescenthealth.org/ ). Publication of the United Nations Convention

on the Rights of the Child in 1989 was another important step toward acknowledging adolescents’

rights as it attributed the rights within the convention to all individuals younger than 18 years of

age (United Nations High Commissioner for Human Rights, 1989). In 2007 The Lancet, which

is recognized as one of the world’s most prestigious medical journals, devoted an entire issue to

the topic of adolescent health for the first time in its 190-year history (Kleinert, 2007). In 2012 it

did so again (Editorial, 2012). Theoretical and empirical interest in the life stage of adolescence

is greater than ever before.One of the most exciting developments in understanding adolescent development over recent

years has been the emergence of MRI data about brain development (McAnarney, 2008). This

has demonstrated that the brain can be subtly remodelled in response to social, emotional, and

behavioral exposure during adolescence (Sawyer et al., 2012, p. 1633). MRI studies also indicate

that the frontal lobe, which is associated with executive functions such as impulse control, deci-

sion making, emotional regulation, and consequential thinking, is one of the last parts of the brain

to mature (Giedd, 2008; Sawyer et al., 2012). This area of the brain continues developing until

individuals reach their mid-20s. In contrast, the limbic system, which is responsible for pleasure

seeking and appetite, develops earlier in adolescence, meaning that in the early and middle parts

of adolescence there is a significant mismatch between these two systems. This is thought to help

explain increases in risk-taking behavior during adolescence, where disconnect occurs betweenadolescents’ affective drives and their ability to rationally regulate these drives (Giedd, 2008;

Sawyer et al., 2012; Steinberg, 2005).

The way in which adolescents’ capacities for planning, judgment, and decision making emerge

also depends on the social and emotional circumstances in which these are enacted (Steinberg,

2005). When making decisions, adolescents are more influenced by exciting and stressful cir-

cumstances than adults, and this is especially true when they are accompanied by peers (Sawyer

et al., 2012). Research continues to demonstrate that little difference exists between adoles-

cents 15 to 16 years of age and adults in relation to capacities for logical reasoning (Grisso

et al., 2003; Grisso & Vierling, 1978; Gustafson & McNamara, 1987; Hale, 1990; Kail, 1997;

Weithorn & Campbell, 1982) but that psychosocial characteristics such as impulse control and

sensation seeking differ, not reaching maturity until early adulthood (Cauffman & Steinberg,

2000; Scott, Reppucci, & Woolard, 1995; Steinberg & Cauffman, 1996). Several authors have

therefore argued that from roughly age 16, adolescents share the same capacities for logic as

adults yet are more influenced by social and emotional cues, which create the differences seen

in actual decision-making outcomes (Cauffman, 1995; Grisso et al., 2003; Martin et al., 2002;

Slovic, 1998; Slovic, 2000; Steinberg, 2004, 2005, 2007, 2008; Steinberg et al., 2008; Steinberg,

Cauffman, Woolard, Graham, & Banich, 2009; Steinberg & Monahan, 2007). The influence of

puberty on behaviour and emotional well-being, as well as propensity for risk-taking, is also

increasingly being recognised (Sawyer et al., 2012; Steinberg, 2005).

http://www.adolescenthealth.org/http://www.adolescenthealth.org/http://www.adolescenthealth.org/http://www.adolescenthealth.org/


5/26


CONFIDENTIALITY WITH ADOLESCENTS

A small body of empirical research exists about confidentiality with adolescents in psychologicalpractice. This has demonstrated that when explicit assurances are provided about confidentiality,

adolescents are more likely to disclose sensitive information (Kobocow et al., 1983). A study of

Australian high school students also found that 98% of adolescents believed that confidentiality

with their school counselor was essential or important (Collins & Knowles, 1995). Studies about

confidentiality between other health professionals and adolescents mirror these findings, demon-

strating the importance that adolescents place on confidentiality and the negative implications of

failing to offer confidential care, such as young people choosing to forgo care rather than risking

their parents being informed about private information (Farrant & Watson, 2004; Ford, Millstein,

Halpern-Felsher, & Irwin, 1997; Jones, Purcell, Singh, & Finer, 2005; Reddy, Fleming, & Swain,

2002; Thrall et al., 2000).Research has also been conducted with psychologists and counselors regarding the man-

agement of confidentiality with adolescents. In a survey of American school counselors, less

than 50% agreement was found regarding confidentiality dilemmas (Davis & Michelson, 1994).

In other studies of American school counselors, decisions about confidentiality with minors were

found to be influenced by the adolescent’s age and the degree of dangerousness of the behavior

(Isaacs & Stone, 1999, 2001). A number of studies have also been conducted in America that

aim to determine under which circumstances psychologists or counselors would breach confi-

dentiality with adolescent clients and what factors influence these decisions (Moyer & Sullivan,

2008; Rae, Sullivan, Razo, & De Alba, 2009; Rae, Sullivan, Razo, George, & Ramirez, 2002;

Sullivan & Moyer, 2008; Sullivan, Ramirez, Rae, Razo, & George, 2002). This body of research

demonstrated that as the intensity, duration, and frequency of a risk behavior increases, so toodoes the propensity for breaching confidentiality. Findings also indicated that with the excep-

tion of extremely high-risk scenarios such as a suicide attempt, psychologists, and counselors

disagreed about when a breach of confidentiality was ethical. Two constructs were found to influ-

ence decisions about confidentiality; the negative nature of the behavior and the therapist–client

relationship. An ongoing theme throughout existing literature is the highly complex nature of

managing confidentiality with adolescent clients (Isaacs & Stone, 1999; Lawrence & Kurpius,

2000; McCurdy & Murray, 2003; Milne, 1995).

THE CURRENT STUDY

For the purposes of the current study, adolescents are defined as those between 12 and 17 years of

age. The current study constitutes the second phase of a broader program of research focusing on

confidentiality dilemmas with adolescent clients. In the first phase, 264 Australian psychologists

participated in an online survey in which they were presented with 68 different hypothetical

vignettes about a 15-year-old boy engaging in risk behavior. The vignettes varied according to the

type, intensity, frequency, and duration of the risk behavior, covering six key behavioral domains:

smoking, sexual behavior, drinking, drug use, suicide, and stealing. In response to each vignette,

psychologists were asked to indicate whether they would breach confidentiality to inform parents

about the risk behavior.


6/26


The findings from this first phase of research were published in two parts (Duncan, Williams,

& Knowles, 2012, 2013). The first publication reported the underlying constructs influencing

psychologists’ decisions, and the second reported psychologists’ responses to the 68 hypotheti-cal vignettes, that is, whether they would breach confidentiality. Four key constructs influenced

psychologists’ decisions: (a) the negative nature of the behavior, (b) maintaining the therapeutic

relationship, (c) the dangerousness of the risk behavior, and (d) legal protection (Duncan et al.,

2012). Psychologists reached consensus about the need to breach confidentiality in 16% of cases

and consensus about not breaching confidentiality in 41% of cases. In the remaining 43% of cases,

disagreement occurred, suggesting a high degree of variation in opinion about appropriate limits

to confidentiality with adolescents (Duncan et al., 2013). Consensus was defined as 80% agree-

ment (Pope, Tabachnick, & Keith-Spiegel, 1988). However, the vignettes presented in this first

phase of the research were hypothetical and so might differ from the decisions that psychologists

make when faced with real dilemmas.The current study aimed to document and explore Australian psychologists’ cases involv-

ing confidentiality dilemmas with adolescent clients. In gathering detailed accounts of past

cases and analyzing the processes that psychologists undertook in reaching a final decision,

it was hoped that a greater understanding would emerge about (a) the types of cases that

Australian psychologists find ethically challenging and (b) the way in which they manage these

cases. A qualitative methodology was chosen so that detailed subjective accounts from psy-

chologists could be documented and explored in a comprehensive manner through individual

interviews.

METHOD

Participants

In 2009, during the first phase of this program of research, an online survey of 264 Australian

psychologists was conducted. At the end of the survey, participants were asked if they would be

willing to take part in a telephone interview to discuss their experiences and opinions regarding

confidentiality with adolescent clients in more detail. Sixty-five participants indicated they were

happy to be contacted. Of these 65, 30 could not be contacted due to problems with the contact

details they had provided (n = 7), being on extended leave (n = 5), or failing to return calls

regarding the study (n = 18). The remaining 35 participants were contacted and provided witha plain language statement and consent form. Participants were also informed at this time that

during the interview they would be asked to provide details about a past case of theirs involving

a confidentiality dilemma with an adolescent client. All 35 agreed to participate in an interview.

One participant could not think of an appropriate case regarding confidentiality and so withdrew

from the study, and one participant could not be contacted at the scheduled time for the interview

and did not return follow-up calls. After interviewing 22 of these 35 participants, no new themes

emerged indicating data saturation and hence recruitment ceased. One interview was not recorded

properly due to a technical failure and in another interview the case discussed involved an 18-

year-old client, which fell outside our definition of adolescence. Following the exclusion of these

two participants, 20 participant interviews were analyzed.


7/26


Materials and Procedure

The current study received ethics approval from a university and hospital Human Research EthicsCommittee. Prior to their interview, participants were asked to reflect on their previous confiden-

tiality dilemmas with adolescent clients and to choose one case they would be willing to discuss in

detail. A time for the interview was then arranged. Interviews were conducted over the telephone

to minimize costs associated with traveling to the several states and territories across Australia in

which participants lived.

A semistructured interview outline was devised. The interview outline incorporated initial

questions about participant demographics, an open-ended request for participants to describe their

chosen case in detail and then a series of more direct prompts to elicit information about their

decision-making processes, the outcomes of the case, and their personal reflections. Throughout

the interviews participants’ responses were reflected and clarified for accurate understanding.Interviews lasted between 41 and 121 min. All interviews were digitally recorded and transcribed

verbatim. Identifying details were removed to protect participants’ identities as well as their

clients’ identities. All participants gave consent to an anonymized version of their case study

being shared in publications or for teaching purposes.

Analysis

Interview transcripts were analyzed by authors RED and ACH in two stages. During the first

stage, interpretive content analysis was used to code and categorize three specific aspects of the

case studies: (a) the type of risk described in the case study, (b) the decision made regarding

confidentiality, and (c) the considerations that influenced the final decision. These three aspectswere selected based on their consistency with the first phase of the research, which focused on

a series of vignettes, the decisions that psychologists would hypothetically make in response to

these, and the considerations that would influence their decision (Duncan et al., 2012; Duncan

et al., 2013). During this first stage of analysis, these specific components of the interview tran-

scripts were identified, categorized, and coded without reviewing other parts of the transcripts

in detail (Downe-Wamboldt, 1992; Graneheim & Lundman, 2004; Hansen, 2006; Rice & Ezzy,

1999; Schamber, 2000). During the second stage of analysis, thematic analysis was employed.

This entailed coding parts of the transcripts that were relevant to the topic of adolescents and

confidentiality more generally, without restrictions on content or preconceived ideas about what

would be most important. During this iterative process, codes were revised and modified sev-

eral times until a final list of discrete and mutually exclusive themes were attained (Creswell,

2014; Hansen, 2006; Rice & Ezzy, 1999). Throughout the analysis process, authors RED and

ACH consulted to discuss categories and emerging themes until consensus was achieved. Both

the interpretive content analysis and thematic analysis were managed using the software program

NVivo (Version 10, QSR International, 2013).

RESULTS

The results are divided into two sections: demographics and case studies. The second section,

describing results from analysis of the case studies, is further divided into two parts to reflect the


8/26


interpretive content analysis and thematic analysis. At the end of all quotes a code is listed to

indicate which participant provided the quote (e.g., P#16 refers to participant number 16).

Participant Demographics

The sample comprised 20 psychologists who all had previous experience working with ado-

lescent clients. Of these 20 participants, 19 were registered psychologists and one was a

provisional psychologist. In Australia, psychologists who are undertaking an internship program

or a postgraduate degree in psychology are registered to practice and are known as provisional

psychologists. Once they have completed these qualifications, they are then registered as a psy-

chologist. After completing further training and supervision in an area of practice, for example,

clinical psychology, they may obtain endorsement in this field. Participants were 80% female,

had been working as psychologists for an average of 11 years (range =

1.5–23 years), and had amean age of 44 years (range = 27–66 years). Half of participants worked in private practice, 35%

worked in schools, and 15% worked in other settings, for example, a government department or

juvenile justice setting. Participants were located across Australia in four of the seven states.

Case Studies

The 20 participants were each asked to provide a description of one case study. However, two

participants provided two cases and one participant provided three cases, meaning that 24 sep-

arate case studies were recorded. Consent was provided to report deidentified versions of all of

these case studies except one, leaving 23 case studies for analysis. Participants described their

case studies in significant detail, often referring back to the case and providing additional infor-mation at multiple points during the interview. Direct quotations for each case study are therefore

extensive, and for this reason only five case studies are included here in full.

The five case studies presented here were selected to convey scenarios with both male and

female clients, a range of client ages, and a variety of risks, including two cases in which the

client is at risk from another individual and three cases in which the client’s own behavior is the

source of the risk.

Case A: 12-year-old boy who witnessed domestic violence

I had a primary school child, whose parents had separated. He first presented with disturbed sleep and

appetite and disturbed mood, very teary all the time, school refusal, which was quite out of character.

Initially one parent [mother] had brought the child to me without the other parent’s knowledge and

then through all of the court processes the child was placed with the other parent [father]. In that

context, the child disclosed witnessing quite severe domestic violence. The child was quite distressed

but there was a federal court order in place for the child being with [the father] and the child was

returned to the parent’s care that night but had disclosed they were very fearful of the parent’s reaction

and the parent had told them they weren’t allowed to tell anybody. I usually let people know when

I’m breaking confidentiality, but in this situation I chose not to inform the child because I felt that

informing the child that I was breaking the confidentiality would increase the child’s anxiety because

I wasn’t able to keep the child in my rooms and not to return home that was outside of my control.

So I did contact child protection and make a notification. The positive impact for him in being placed

with his mum were his mood improved, his sleep improved, his appetite improved, he was enjoying

school, he felt safe and all of those things and yeah a huge improvement for him. P#1


9/26


Case F: 15-year-old boy engaging in self-harm

So there was a young fella. His mother had concerns about him acting out in school and she outlineda history of bullying that he had been subjected to that had been really significant since Grade 2. He

was now in Year 9. So there was some self-harming that became evident but I didn’t push too hard.

In the second session he’s disclosed the further extent of self-harm. He was sniffing glue, cigarette

burns on his skin by himself. He reported having attempted to choke himself with a rope on three

occasions and of attempting to drown himself in a bath. He’d also spoken about asking people to hit

him at school and stuff like that. Hot glue onto his skin as well. He was able to indicate to me that

the reason he did these things was because he wanted to feel something, to escape from feeling numb

and shut down, he reported no current plans or intention regarding suicidal behaviours however he

acknowledged ongoing thoughts regarding risk taking behaviours. Mum was aware he’d cut himself

before but she wasn’t aware of anything more extreme than that. I’ve indicated to him oh that’s stuff

I’ve got to tell your mum, you know that’s pretty heavy duty stuff and you know your brain’s such a

young precious thing right now and you don’t want to wreck it. He was a smart boy and he knew thathis mum needed to know this stuff as well. He was concerned about how his father would react so I

indicated to him that I’m going to tell mum but the question is when and I’m prepared to give you

some time to tell her. So basically I gave him a week to tell her and I then spoke to her the next week

and she had heard from him. I clarified the extent that he’d reported and it appeared that he’d done a

full disclosure. P#6

Case O: 14-year-old girl having sex with a 17-year-old boy

A 14-year-old who was in an ongoing sexual relationship with a person who was about two and a half

years older than her. She was quite clear that she had been the instigator of the relationship and when

she came to me it had been going on for about six months. Technically, I think he was 17, technically

that was illegal but I certainly didn’t consider reporting it because that would have just devastated her

life and his and I didn’t believe she was a victim in that circumstance. Now other people would have,

and I was breaking the law and I’m aware of that. She was a young girl who had very little support

from her parents and it was a very disruptive chaotic home and she had moved out and moved in,

living most of the time with this young man in a fairly nurturing relationship. She was a fairly out

there kid, she was quite provocative in relationship to a number of the authority figures in the school

and she was on her own in life at 14 and had been for many years I think really. I thought, what’s

the choices, if I reported her and DHS had walked in and taken her out and tried to put her into some

sort of foster or group home she’d have run away and she’d have been on the street and disrupted

everything, it would have destroyed her life. P#15

Case Q: 15-year-old girl involved in a sexting incident

When I was working at the school we had a young girl and she would’ve been about 15. She’d been

seeing this boy for so many weeks and she sent him a text message of herself naked. So this boy has

it on his phone, takes it to school, someone picks up his phone starts going through photos sees this

photo. And so the girl is all distraught, comes to see me as the school psychologist. It doesn’t take

long for the whole school to sort of be aware but I mean the teachers actually at this point had no idea.

So then I guess I was faced with the issue, well do I have to tell, do I tell the parents? Do I tell the

school? And what do we actually do about it? It was difficult because although we’re faced with the

issue of, you know, what’s happening for this child we’re also faced with a legal issue of the photo

and the fact that it can be viewed as child pornography depending on the behaviour of the people that

have possession of the photo. I mean even if she had’ve said ‘no no no you can’t tell anyone’ I still,

I would have just kept talking to her until she was I guess, convinced isn’t the right word that I want


10/26


to use, but until she was sure that it was the right decision to make because I felt in that case because

of her age and because of everything else it really was. But in this case she did know something had

to be done and she trusted my judgement for what that would be. I did let the young girl know thatI’m going to have to tell the teachers, I’m going to have to tell her parents and although she was very

upset and petrified of what her mum and dad were going to think she was actually okay with that and

we got mum into the school and we all sat down and had a chat together P#17

Case U: 16-year-old girl being pressured for sex by family member

I had a young woman, 16, who was an international student. She came to me in a state of great distress.

She was staying with a family of cousins and the young man in the family had said he wanted to sleep

with her and she had tried to say no, no, no and he had put the hard word on her and also found that

she had a mobile phone with a boyfriend’s number in it and said that if she didn’t sleep with him he

was going to blow her cover and say that he knew she had a boyfriend and that she had been sleepingwith him and she was a slut. She was terrified. She came in just saying ‘I’m going to kill myself,

there’s nothing I can do.’ It took a few hours to get the story together and we said you’re not going

to kill yourself, we’re going to fix it, this will be alright, you will get through this, you will not be

raped, we will make sure you’re not, but we are going to have to tell people. And then of course she

got absolutely hysterical. She said ‘no, miss, no, don’t say, don’t say, it’ll be terrible, it’ll be worse.’

And I did and it was very difficult. I went firstly to the principal. We decided that she couldn’t go

home and we spent the whole day on it. Together we rang the out of home care people who deal with

international students and they were no help. We rang DHS and they found a place for her to go but

in the course of the conversation the principal said that she felt so frightened that she had thought of

killing herself and they pulled the plug on that and wouldn’t have her. This was five o’clock. We asked

to see the mother in the household. She denied that it was happening, said that her son would in no

way do that. We got an overnight bag and then we were left with nowhere to keep her. So I said tothe principal I would take her home. I wasn’t very comfortable. She ended up staying with me for

three days. The major breach of confidentiality was when we rang her parents back home overseas

and spoke to her father. He came and arranged other accommodation. I met her about four years later

and she said ‘Miss, do you remember me?’ She said ‘Now my parents have come out I’m living with

them and I’m just finishing accountancy and thank you so much.’ P#15

Interpretive Content Analysis

Three aspects of the 23 case studies were coded using interpretive content analysis: (a) the type

of risk, (b) the decision made regarding confidentiality, and (c) the primary consideration that

influenced the decision. Table 1 presents a summary of the 23 case studies, the type of risk

described in each, and to whom the disclosure of information was made, if a disclosure occurred.

The age and gender of the client and the psychologist’s workplace setting are also included. The

mean client age was 14.8 years (range = 12–17), and nine cases involved a male client (39%).

Two cases involved an explicit risk of suicide; seven involved clients who were self-harming; two

involved domestic violence; three involved consensual sexual activity; and the remaining cases

entailed a range of other risks including missing school, sexting, drug taking, threatening others,

and unwanted sex or sexual advances. Half of the clients (50%) were seen by psychologists in

private practice, 45% were seen by psychologists in a school setting, and one client (5%) was

seen in a juvenile justice setting. When disclosures occurred, information was most commonly

shared with the client’s parents, usually the mother. Disclosures were also made to protective


11/26

T A B L E 1

S u m

m a r y o f t h e A g e ,

S e x ,

S e t t i n g , a n d R i s k f o r t h e 2 3 C a s e S t u d i e s P r o v i d e d b y P a r t i c i p a n t s

C a s e

C l i e n t A g e

( Y e a r s )

C l i e n t G e n d

e r

R i s k

S e t t i n g

P e r s o n t o W h o m I n f o r m a t i o n W a s D i s c l o s e d

A

1 2

M a l e

W i t n e s s e d s i g n i fi c a n t d o m e s t i c

v i o l e n c e

P r i v a t e P r a c t i c e

C

h i l d P r o t e c t i o n A g e n c y

B

1 4

M a l e

S e x u a l a b u s e


T

h e c o u r t

C

1 4

M a l e

V i c t i m o f f a t h e r ’ s p h y s i c a l a b u

s e

S c h o o l

C

h i l d p r o t e c t i o n a g e n c y

D

1 4

M a l e

S e l f - h a r m , s u i c i d a l , t h r e a t t o h a r m f a m i l y

S c h o o l

P

a r e n t s

E

1 4

M a l e

S h a r i n g i n f o r m a t i o n f r o m a s s e s s m e n t

S c h o o l

P

r i n c i p a l

F

1 5

M a l e

E n g a g i n g i n s e l f - h a r m


C

l i e n t d i s c l o s e d t o m o t h e r

G

1 5

M a l e

T h r e a t e n i n g t o p l a n t b o m b i n s

c h o o l

S c h o o l

T

e a c h e r i n i t i a l l y , t h e n h e a d o f h o u s e a t s c h o o l a n d

m o t h e r

H

1 5

M a l e

B e i n g t a k e n t o c o u r t f o r s t e a l i n

g

S c h o o l

M

o t h e r

I

1 7

M a l e

B r e a c h i n g i n t e r v e n t i o n o r d e r

J u v e n i l e J u s t i c e

P

o l i c e w i t h a p p l i c a t i o n t o c o u r t t o h a v e c l i e n t d e t a i n e d

J

1 3

F e m a l e

B e i n g b u l l i e d a n d s n e a k i n g o u t a t n i g h t


N

o d i s c l o s u r e

K

1 4

F e m a l e

S e x u a l l y a c t i v e a n d h a d a n a b o

r t i o n


C

l i e n t d i s c l o s e d t o m o t h e r

L

1 4

F e m a l e

V i c t i m o f e m o t i o n a l a b u s e & s

e l f - h a r m


M

o t h e r

M

1 4

F e m a l e


S c h o o l

N


N

1 4

F e m a l e

C o m b i n i n g b i n g e d r i n k i n g a n d

s e l f - h a r m

S c h o o l

M

o t h e r

O

1 4

F e m a l e

S e x u a l r e l a t i o n s h i p w i t h 1 7 - y e

a r - o l d

S c h o o l

N


P

1 5

F e m a l e

P o t e n t i a l f o r s u i c i d e


N


Q

1 5

F e m a l e

S e x t i n g i n c i d e n t

S c h o o l

P

a r e n t s a n d s c h o o l ( w e l l - b e i n g c o o r d i n a t o r a n d

p r i n c i p a l )

R

1 6

F e m a l e

M i s s i n g s c h o o l d u e t o I n t e r n e t

a d d i c t i o n


N


S

1 6

F e m a l e

H a d t a k e n p a r e n t s ’ m e d i c a t i o n

s


M

o t h e r

T

1 6

F e m a l e

U n s a f e s e x u a l p r a c t i c e s


N


U

1 6

F e m a l e

B e i n g p r e s s u r e d a n d b u l l i e d f o

r s e x

S c h o o l

P

r i n c i p a l , p r o t e c t i v e s e r v i c e s , r e l a t i v e c l i e n t w a s l i v i n g

w i t h , p a r e n t s ( o v e r s e a s )

V

1 7

F e m a l e

D i s c l o s u r e o f r a p e


P

a r e n t s

W

1 7

F e m a l e



N


206


12/26


services, teachers, school principals, the court, and in one case a family relative. In some cases

more than one of these third parties was informed about the same information.

The decisions made across the 23 case studies fell into five distinct decision types. As demon-strated in Table 2, these can be conceptualized on a spectrum related to the degree of autonomy

that the adolescent client was afforded. At one end of the spectrum is a decision to maintain

confidentiality in full (Decision Type 1), which entails the highest degree of client autonomy.

At the other end of the spectrum is a decision to disclose information to a third party without

the client’s knowledge or the client’s consent (Decision Type 5). This entails the lowest degree

of client autonomy. The three decision types sitting between these two extremes involve varying

degrees of client autonomy: one in which disclosure is enacted by the client (Decision Type 2),

one in which disclosure is enacted by the psychologist with the knowledge and consent of the

client (Decision Type 3), and one in which disclosure is enacted by the psychologist with the

client’s knowledge but without the client’s consent (Decision Type 4).Case O represents the first decision type; where confidentiality is maintained in full:

I certainly didn’t consider reporting it because that would have just devastated her life and his. P#15

Case F represents the second decision type; disclosure by the client, facilitated by strong

encouragement from the psychologist:

So I indicated to him that I’m going to tell mum but the question is when and I’m prepared to give

you some time to tell her. So basically I gave him a week to tell her and I then spoke to her the next

week and she had heard from him. I clarified the extent that he’d reported and it appeared that he’d

done a full disclosure. P#6

Case Q represents the third decision type; disclosure by the psychologist with the client’s consentand knowledge:

I did let the young girl know that I’m going to have to tell the teachers, I’m going to have to tell her

parents and although she was very upset and petrified of what her mum and dad were going to think

she was actually okay with that and we got mum into the school and we all sat down and had a chat

together. P#17

Case U represents the fourth decision type; disclosure with the client’s knowledge but without

the client’s consent:

She said ‘no miss, no don’t say, don’t say it’ll be terrible it’ll be worse’, and I did and it was very

difficult. P#15

Finally, Case A represents the fifth decision type; disclosure without the client’s consent or

knowledge:

I usually let people know when I’m breaking confidentiality, but in this situation I chose not to inform

the child because I felt that informing the child that I was breaking the confidentiality would increase

the child’s anxiety because I wasn’t able to keep the child in my rooms and not to return home that

was outside of my control. So I did contact child protection and make a notification. P#1

Participants used a variety of considerations in reaching their decisions about confidentiality.

In 16 cases, participants balanced multiple primary considerations to reach a final decision, and

in only seven cases did participants describe being able to make their final decision based on one


13/26

T A B L E 2

A S u m m a r y o f t h e D e c i s i o n s M a d e R e

g a r d i n g C o n fi d e n t i a l i t y A c r o s s t h e 2

3 C a s e S t u d i e s

D e c i s i o n T y p e

C a s e

R i s k

1

C o n fi d e n t i a l i t y

M a i n t a i n e d

2

D i s c l o s u r e

b y C l i e n t

W i t h E n c o u r a g e m e n t

F r o m P s y

c h o l o g i s t

3

D i s c l o s u r e b y

P s y c h o l o g i s t W i t h C l i e n t

K n o w l e d g e a n d C l i e n t

C o n s e n t

4


P s y c h o l o g i s t W i t h C l i e n t

K n o w l e d g e b u t N o t W i t h

C l i e n t C o n s e n t

5


P s y c h o l o g i s t W i t h o u t

C l i e n t K

n o w l e d g e o r

C l i e n t C o n s e n t

J

B e i n g b u l l i e d a n d s n e a k i n g o u t a t n i g h t

M


O

S e x u a l r e l a t i o n s h i p w i t h 1 7 - y e a r -

o l d

P


R

M i s s i n g s c h o o l d u e t o I n t e r n e t a d

d i c t i o n

T


W


F


K

S e x u a l l y a c t i v e a n d h a d a n a b o r t i o n

B


D

S e l f - h a r m , s u i c i d a l i d e a t i o n , t h r e a t t o

h a r m f a m i l y

G

T h r e a t e n i n g t o p l a n t b o m b i n s c h o o l

L

V i c t i m o f e m o t i o n a l a b u s e & s e l f

- h a r m

Q


H

B e i n g t a k e n t o c o u r t f o r s t e a l i n g

N

C o m b i n i n g b i n g e d r i n k i n g w i t h

s e l f - h a r m

S

H a d t a k e n p a r e n t ’ s m e d i c a t i o n s

U

B e i n g p r e s s u r e d a n d b u l l i e d f o r s e x

V


A

W i t n e s s e d s i g n i fi c a n t d o m e s t i c v i o l e n c e

C

V i c t i m o f f a t h e r ’ s p h y s i c a l a b u s e

E

S h a r i n g i n f o r m a t i o n f r o m a s s e s s m

e n t

I

B r e a c h i n g i n t e r v e n t i o n o r d e r

208


14/26


consideration alone. Eleven distinct primary considerations were described by participants; these

are presented in Table 3. Table 4 presents the range of primary considerations that were balanced

in each case.

Thematic Analysis

Two themes emerged from the thematic analysis: strategies for minimizing harm, and personal

costs. Participants described a range of strategies that they employed to minimize the potential

for harm when managing confidentiality with adolescent clients. The strategies fell into five cate-

gories: conducting thorough risk assessments, maintaining the therapeutic alliance, empowering

the client, supporting the family, and professional safety.

Several participants referred to conducting a thorough risk assessment as a vital part of

ensuring they had all the necessary information to make a professional judgment.So you always sort of mentally have a staircase . . . where’s the risk here . . . and that’s how I treat

issues of confidentiality. . . . There’s a staircase and at each stage I’m saying, I’m testing whether or

not this should go further or whether it stays with us. P#10

TABLE 3

Primary Considerations Used by Participants in Deciding Whether to Breach Confidentiality With Their

Adolescent Client

Primary Consideration

No. of

Participants Quote

Immediate risk of harm 11 “That was a really important intervention because she would have been

raped I’m absolutely certain of that” P#15

Best interests of the client 10 “If I can get some change that ends up being a positive outcome for the

young person . . . then I do that.” P#14

Future risk of harm 8 “I was worried that she could be put in that situation . . . where she had

contact with him again.” P#19

Duty of care 6 “As a psychologist I’ve a duty of care to look after young people and

make sure they are safe.” P#14

Likely parental reaction 5 “That’s always a consideration, you know, what risk are you putting the

child at by involving the parents. P#11

Relationship between client

and parent(s)

4 “I hadn’t had contact with them and I didn’t know whether that was a

positive relationship . . . whether that could actually have a negativeoutcome” P#1

Age 3 “I felt in that case because of her age and . . . everything else it really

was . . . just such a huge issue.” P#17

Impact on therapeutic

relationship

2 “If I broke confidentiality she wouldn’t come back for treatment so I

thought that in terms of engaging her in treatment the most important

thing was the confidentiality and assurance.” P#18

Mandatory reporting

guidelines

2 “We were in a position of having to report. . . . We felt that we had no

choice but to ring the authorities.” P#3

Maturity 1 “She was one of those very mature, what we call you know mature

minor you know very independent.” P#16

Client consent for Release

of Information

1 “Then I was contacted with a release of that client . . . to provide

information to the court.” P#2

Note. P# = participant number.


15/26

T A B L E 4

T h e R a n g e o f P r i m a r y C o n s i d e r a t i o n s T h a t W e r e B a l a n c e d i n E a c h C

a s e

C o n s i d e r a t i o n s

C a s e

R i s k

I m m e d i a t e

R

i s k o f

H a r m

B e s t

I n t e r e s t s o f

t h e C l i e n t

F u t u r e

R i s k o f

H a r m

D u t y o f

C a r e

L i k e l y

P a r e n t a l

R e a c t i o n

C l i e n t – P a r e n t

R e l a t i o n s h i p

A g

e

I m p a c t o n

T h e r a p e u t i c

R e l a t i o n s h i p

M a n d a t o r y

R e p o r t i n g

O b l i g a t i o n s M a t u r i t y

C l i e n t

C o n s e n t f o r

R e l e a s e o f

I n f o r m a t i o n

J

B e i n g b u l l i e d a n d s n e a k i n g

o u t a t n i g h t

M


O

H a v i n g s e x w i t h

1 7 - y e a r - o l d

P


R

M i s s i n g s c h o o l d u e t o

I n t e r n e t a d d i c t i o n

T


W


F


K

S e x u a l l y a c t i v e a n d h a d a n

a b o r t i o n

B


D

S e l f - h a r m , s u i c i d a l , p l a n s t o

h a r m f a m i l y

G

T h r e a t e n i n g t o p l a n t b o m b

i n s c h o o l

L

V i c t i m o f b r o t h e r ’ s a b u s e ;

s e l f - h a r m

Q


H

B e i n g t a k e n t o c o u r t f o r

s t e a l i n g

N

B i n g e d r i n k i n g a n d

s e l f - h a r m

S

H a d t a k e n p a r e n t s ’

m e d i c a t i o n s

U

B e i n g p r e s s u r e d a n d b u l l i e d

f o r s e x

210


16/26

V


A

W i t n e s s e d s i g n i fi c a n t

d o m e s t i c v i o l e n c e

C

V i c t i m o f f a t h e r ’ s p h y s i c a l

a b u s e

E

S h a r i n g i n f o r m a t i o n f r o m

a s s e s s m e n t

I

B r e a c h i n g i n t e r v e n t i o n

o r d e r

211


17/26


Strategies related to maintaining the therapeutic alliance included discussing limits to confiden-

tiality at the start of therapy and referring back to these when breaches were necessary, openly

discussing the rationale for any breaches, gaining the client’s trust through initial smaller dis-closures, restricting disclosures to those with a clear need to know, and supporting the client

throughout the process of any breaches that occur:

I’d sort of say . . . your information’s private, I’m not going to speak to your mum about everything

that we talk about here, but if I become concerned about stuff and indeed really scared and if you and

I sort of can’t work it out . . . I might have to tell her some things. . . . And I’ll tell you what those

things are before, we’ll sort of talk about it so you’re gonna know what’s gonna happen but that’s

the way I sort of operate. . . . And if he can’t handle that well then obviously we don’t proceed but

that’s sort of generally how it goes then I’ll ask him basically some questions, does that seem clear to

you? Are you okay with that? . . . and then usually they’ll say yes and then we’ll sort of go on from

there. P#6

The way I used to work it . . . I’d pick a little bit and I’d pick somebody I knew they liked. . . . I said

to him at one stage ‘I want to have a chat with your English teacher’ . . . casting it in terms of his

writing, ‘Have you written about any of this stuff?’ . . . ‘Yes I have’ he said, so that gave me the in,

so then I talked to the English teacher and let him see that nothing happened. P#7

Strategies used to empower the client included allowing the client to be involved in decisions

about the timing of the disclosure, what information was shared, and to whom the information was

disclosed. Clients were also often given the opportunity to disclose the information themselves

first or to be present when the psychologist made the disclosure.

Well I went back to what I’d talked about in the first session and said to her well these were the

options, that either we contacted someone from her family and involved them in the plan to keep her

safe or that we might have to go down the mental health avenue as well. . . . And she responded that

yes she would contact a friend so a friend who was I think she was in her thirties, because she didn’t

want me to contact her mum, so a close friend came to the office with her and we finished the session

together, put together a plan in terms of her safety. P#1

I said actually we did speak about confidentiality in the beginning and this is one of those examples

because you are putting yourself at risk and because of these reasons I do need to talk to your mum,

but what I’m prepared to do is give you an opportunity to have a chat with her and then I’ll follow

up with you in a week so that it’s not coming from me. . . . So when I followed up she hadn’t done

it and she pretty well told me that she hated me and that was it and hung up and that was the end of

it, she knew that I was going to follow up which is exactly what I did. So I made an appointment to

meet with mum and then when mum came in she’d already told her, which is what I wanted in the

beginning anyway. P#11

Now do you want me to ring mum about this or do you want me to let your teachers know or will we

just keep it between us. . . . That sort of thing, so I’m a great believer in empowering the students.

P#13

Participants also spoke about strategies they put in place to support the family more broadly, such

as arranging support for parents and modelling positive ways of reacting for parents.

Her initial reaction was going to be to kick the girl out. She felt like she’d already had enough issues

with this girl over time so I did a lot of work around what were the reasons why this girl may have

done what she did and . . . what’s the way to manage this without putting her at further risk of harm.


18/26


. . . We also got mum some separate help and support for herself to be able to process what was

happening. P#19

I talked to mum about . . . the issues. . . . I didn’t believe that she needed to be punished or anything

like that obviously mum had to address some stuff with her but I felt that the punishment was enough

the fact that she so didn’t want her mum to know. P#11

Several strategies aimed at professional safety were also used by participants, such as access-

ing supervision, consulting with colleagues, and documenting the situation and decision-making

process thoroughly.

I spent quite a bit of time documenting the pros and cons and weighing up the potential harm one

way or another. P#16

I had two very senior men that I had supervision from, one is one of [city’s] top family and adolescentpsychiatrists, I invited him a number of years before to supervise the counselling group which he did,

so I sought his counsel on this case and also a very senior [city] psychologist who’s been around for

a long time whose work with adolescents and families I respect. P#7

Table 5 presents a list of the strategies used by participants in attempting to minimize the

potential for harm when managing confidentiality with adolescent clients.

TABLE 5

Strategies Employed by Participants for Minimising Harm in Relation to Confidentiality With Adolescent

Clients

Risk assessment • Conducting a thorough risk assessment in order to determine whether

confidentiality might need to be breached

Strategies for maintaining the therapeutic

alliance

• Discuss confidentiality and limits to confidentiality at the start of

therapy

• Refer back to initial explanation of confidentiality

• Openly discuss the rationale for breaching confidentiality with the

client

• Gain trust and confidence through initial smaller disclosures

• Support the client through the breach of confidentiality

• Restrict disclosure to those with a clear need to know

Strategies for empowering the client •

Allow client to be involved in decision about timing of the disclosure• Allow client to be involved in decision about what information is

shared

• Allow client to be involved in decision about who to disclose to

• Provide client with opportunity to disclose to parent(s) themselves

• Provide client with opportunity to be present while psychologist

disclosesa

Strategies for supporting the family • Provide support to parents around disclosure

• Model positive ways of reacting to news for parents

Overarching strategies • Access supervision

• Consult with colleagues

• Document the situation and decision-making process thoroughly

a

Could equally fit under strategies for maintaining the client-therapist relationship.


19/26


The second key theme to emerge from the interviews with participants was the personal cost

that managing confidentiality had on them at times. One participant highlighted the particular

challenges of working in private practice:

It’s very difficult when you’re in private practice, like having worked a lot in teams . . . you can

always go and talk to people . . . but when you’re there in the office by yourself . . . you have to work

through that and take the responsibility yourself so it is a bit harder. P#1

Other participants felt worried about whether they had made the right decision:

It was one of those fingers crossed behind backs scenarios which, working with a lot of my

clients I have quite a bit of doing that . . . you know it was touch and go whether I’d done the

right thing. P#16

Some also referred to the stress they experienced:

I had plenty of sleepless nights. P#7

I was really aware even then that I was documenting in the event that I was going to be fronting a

coronial enquiry. P#16

That’s the only time I’ve had a client come home and stay overnight but I was not comfortable with

it but we were caught and I felt, my principal who was male couldn’t really take her. P#15

Confidentiality issues I think are very ah stressful and I think people need to be aware that that’s sort

of part of the process. P#6

Some participants also talked about the criticism they have experienced from their peers aboutdecisions they have made regarding confidentiality with adolescents:

Certainly open to criticism for not having done so and having done so and I’ve been criticised on both

ends. P#15

DISCUSSION

The current study aimed to document and explore Australian psychologists’ ethical dilemmas

involving confidentiality with adolescent clients. Twenty participants took part in semistructured

in-depth interviews, and they provided detailed accounts of 23 past cases in which they had nav-

igated a confidentiality dilemma with an adolescent client. These candid descriptions provide

a unique insight into the complexities associated with managing confidentiality with adoles-

cents. The findings also extend previous research that has been hypothetical in nature as they are

embedded in actual psychological practice. For the first time, the current study therefore provides

information about the broad range of confidentiality dilemmas that Australian psychologists face

with adolescent clients, the key considerations that influence their thinking in response to these

dilemmas, and the variety of decisions that they ultimately make. The study also provides novel

information about the range of strategies that are used to minimize harm when managing confi-

dentiality dilemmas with adolescents and the personal costs that can accompany these dilemmas.

Three key findings are discussed.


20/26

8/18/2019 Duncan Et Al 2015 Ethical Dilemmas of Confidentiality Wit

duncan et al 2015 ethical dilemmas of confidentiality with adolescent clients case studies from...

Documents