Ethical Dilemmas: Breaking Confidentiality

One crucial factor that influences our behaviour towards others, our everyday interactions, our decisions and many other areas of our lives is our personal values. The personal values of an individual are important to them and have a lasting effect. A person develops their values while growing up and are influenced by the culture this person is a member of. Values have a great impact on peoples’ attitudes and behaviours and they are the basic guidelines were individuals refer to when faced with a dilemma. They are a reflection of an individual’s sense of right and wrong.

According to sociologist Morris Massey values are not innate but are developing throughout our life. More specifically, he suggested three major periods in a person’s life, the imprint, the modelling and the socialization periods, were values are developed. The imprint period lasts until the age of seven and during this period we absorb everything that is in our environment and accept most of what we see and hear as true. What is important during this period is to develop a sense of what is right and wrong, and what is good and bad. Afterwards, comes the modelling period were it is between the ages of eight and thirteen. During this period we tend to mirror and copy what others do. It is a time of trying out various values to see how they work and how they feel for us. The parents take a back seat on how much they influence our own values and beliefs and teachers seem to be a source for us on developing new values. The last period of forming our values according to Massey, is the socialization period which lasts from the age of thirteen until the age of twenty-one. During this period, the main source of influence is our peers. Additionally, nowadays a great source of information but also an influence of our values is the media.

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By the age of approximately twenty-one we have developed a set of values that we have as a reference when we are faced with a dilemma. This set of values is our personal ethical guidelines when we are even faced with ethical issues in our professional life. Sometimes though, we are bound to follow the values and guidelines of the organization we are working for or the law of the country we are living in which might come in contrast with our personal values. For example, many psychologists have rated the topic of breaking confidentiality as a frequent ethical troubling incident that they face (Pope & Vetter, 1992). The law says that we need to break confidentiality in cases where the client or other parties are in danger however, the American Psychological Association stresses the importance of not breaking confidentiality (American Psychological Association, 2002). Thus, when psychologists encounter a situation like this, is down to their own values what course of action they will take. While making a decision, the psychologists need to have in mind the well-being of the client and others, and need to be truthful and deal honestly with the client.

It is important that in each of our professional decisions, especially when ethical dilemmas arise, to have in mind the multiple dimensions the client has and that our decision will possibly affect all these areas of the client’s life. When psychologists are faced with a professional ethical dilemma where the guidelines of the association they are members cannot help them to draw to a conclusive decision they can turn to models. Decision making models are a way to help professionals reach a decision in complicated cases. With the help of a decision making model the professional will be able to gather all the information they have together. Moreover, by using a model the psychologist will reach a decision based on various parameters and not only what the law or the ethical guidelines suggest.

The case of Sam

Sam is a twenty years old male. He is in the third year of his university studies. He sought help by visiting the university’s counselling services after his friends insisted that he should “get some help”. Sam disclosed to the psychologist that he is a regular cannabis user for the past two years. His friends told him they were concerned for him because even when he was not under the influence of the drug he was behaving “weirdly” and “aggressively” towards others the past few weeks.

After a thorough assessment by the center’s psychologist it was obvious that Sam had a psychotic episode. When he was asked about his family’s medical and mental history it was found that one of his aunt’s had schizophrenia. The psychologist informed Sam about the results of his assessment and that further treatment both medical and psychological, would be advisable. However, Sam was not willing to engage in any treatment and refused to believe the possibility of a recurrent psychotic episode. Additionally, when the psychologist suggested that Sam should inform his parents he did not agree. Fortunately, he did not stop coming to the meetings with the psychologist but Sam gradually became more aggressive and violent towards others.

Now, the psychologist is presented with the following dilemma, should she keeps confidentiality and tries to deal with Sam’s symptoms only during therapy or should she inform his parents or the university about his symptoms and refusal to seek treatment? The reason for thinking about breaking confidentiality is because if Sam does not seek medical treatment and he has another psychotic episode there is a chance of harming others. What is more, he is still regularly using cannabis which only worsens his current mental state and makes him more aggressive.

Discussing literature

Therapy is a collaborative process between the client and the therapist and thus, to have the desired therapeutic outcome trust is a necessary component of it. This is the reason why in the ethics codes confidentiality in clinical practice is always a very important code to know. According to the American Psychological Association (2002), the psychologist has a primary obligation to protect the information shared during therapy and to take the necessary precautions to prevent otherwise. Most of the other associations agree with this statement and stress the importance of guarding the personal information and sensitive details we get to hear during therapy. As Beck (2001) says “Without confidentiality there can be no trust; without trust there can be no therapy”.

However, in some instances the confidentiality code is not applicable. For example the Canadian Counseling Association (2007) proposes three cases were confidentiality can and sometimes should brake. In particular, it suggests that in cases where we need to protect a child, or when legal requirements force us or when there is an immediate danger for the client or other people then we should consider breaking confidentiality. Despite the ethical guidelines of when it is acceptable to break confidentiality it is still down to the psychologist’s values and ethics what they will decide.

In the case of Sam, the psychologist is faced with a variety of questions. Should she break confidentiality and let his parents know about his psychotic episode? Should she inform the parents of Sam’s refusal for further assessment and treatment? Does she have to report Sam to the university’s security as a possible threat to the rest of the university’s students? What if he has another psychotic episode and he goes and hurts or even kills somebody?

According to the ethics guidelines since there is no immediate threat for Sam or others the psychologist possibly should not break confidentiality. However, there is growing literature showing that parents and in extent caregivers should be aware and have access to the health information of their relatives with mental illness (Chan & O’Brien, 2011). Incidents like the one of Nadia Kajouji in 2008 raise the question of whether psychologists ought to share the information they have with family members without consent when it is necessary for assisting in the recovery of their loved one. In the case of Nadia her parents were not aware she was experiencing severe mental difficulties and when she eventually committed suicide the parents were caught by surprise. What is more, they were deprived from having the chance to help in the treatment of their daughter (Chan & O’Brien, 2011). When the case went to court, the psychologist and organization they were working in was not found guilty it is questionable though if the decision of the psychologist was ethical or not since it lead to the death of their client.

Therefore, there is a need for a balance between protecting our client’s right to confidentiality and privacy and the right of parents and caregivers to have access in relevant information when it is necessary for the promotion of the therapeutic process of the client. When parents and caregivers are left out of the treatment process they oftentimes feel powerless in managing the everyday challenges that arise from our client’s behaviour. What is more, there are cases were the caregivers are put into risk by not knowing sensitive but important information about the person they care for mental health (Wynaden & Orb, 2005).

By having access to some confidential information, caregivers and parents can make sure to provide the individual with the necessary support and prevent further deterioration of their mental health. Additionally, they will have the opportunity and responsibility of reducing the risk of serious physical or psychological harm of the individual and of others (Select Committee on Mental Health and Addictions, 2010). In particular, in the case of psychotic symptoms the clients are likely to act physically violent to others. What is more, the most likely people who will be the receivers of such violent acts will be the client’s family members (Arboleda-Florez, Holley & Cristanti, 1996). Consequently, sometimes it is important not only to follow the ethical guidelines and laws of confidentiality but also have in mind the welfare of our clients.

Psychologists sometimes interpret confidentiality as not being able to disclose anything to other parties. In some instances because of this misconception they fail to provide their clients with the choice of disclosing and take the decision of not sharing information with others all by themselves without consulting the client (Marshall & Solomon, 2003). On the other hand, families and caregivers believe that if there is any information that is really crucial for the treatment of the client, the psychologist will automatically share it with them (Marshall & Solomon, 2000). As we can see there are various views about what confidentiality is and how it is implemented. What is more, this variability is evident among professionals as well (Marshall & Solomon, 2003).

From the above, we can come to the conclusion that what psychologists’ think as confidentiality and ways of implementing it are different from what caregivers and family believes. What is more, the actions for guarding confidentiality and releasing appropriate information to other parties do not follow a standard procedure. Because of this, there seems to be a barrier between the psychologist, the client and their family or caregivers which at times prevents the best outcomes of therapy and might lead to unfortunate events in the cases of serious mental illnesses.

What literature suggests is the development of consistent procedures for breaking confidentiality and releasing information to caregivers and families. What is more, the ethical guidelines would be advisable to clarify that it is the client’s choice whether to let their caregivers know about their situation or not. Additionally, a consent form would be more likely to be signed by the client as a matter of routine instead when this person is in crisis. Thus, psychologists could initiate the consent process for disclosing information to families and caregivers semiannually or annually (Marshall & Solomon, 2003). Chan and O’Brien (2011) even suggested a decision model that can be seen in figure 1, for professionals to follow when they need to balance confidentiality and the right of family and caregivers to access information about their relative.

Decision making model

When we are facing an ethical dilemma during our practice it is normal to experience a variety of emotions, such as anxiety and confusion that will interfere with our decision making process. Therefore, it would be advisable to have in mind an ethical decision making model which we would use in times like this to help us reach a decision more easily. Using a model of decision-making, makes us feel more confident in the sense that we included in our decision various parameters of the dilemma.

The model each professional will use depends on their own style and personal preference. However, the majority of the decision making models include the components of culture and context, consultation, personal and professional judgment as well as the law the professional practices and codes of their association (Evans, Levitt & Henning, 2012).

Figure 1. A proposed decision tree to balance the need to protect confidentiality of clients with the right of caregivers to access health information of their mentally ill relatives (Chan and O’Brien, 2011).

During ethical decision making absolute thinking and utilitarian thinking are involved. By absolute thinking we mean thinking about our rights but also our duties. By utilitarian thinking we mean that we need to do what is in the best interest of our clients but by having in mind doing simultaneously the greatest good for the greatest number of people (Cottone & Claus, 2000). The professional’s values and moral beliefs influence how they will act when faced with an ethical dilemma. Thus, an ethical decision making model helps the psychologist to reach a decision while at the same time it reduces the impact of the psychologist’s values on the process.

The model I chose to use for analysing the case of Sam is the Ethical Justification model introduced in 1984, by Kitchener. It draws from the work of Hare’s (1981) on the levels of moral thinking and the suggested ethical principles of Beauchamp and Childress (1979) being, autonomy, nonmaleficence, justice and beneficence (Cottone & Claus, 2000). The reason I chose such an old model despite new ones being published through the years is because most of the new models are based on Kitchener’s work. Moreover, in a study by Dinger Kitchener’s work was found to be more efficient in equipping professionals with the required skills to tackle ethical dilemmas whatever the scenario (Cottone & Claus, 2000).

The ethical decision making model by Kitchener (1984) suggests nine steps in the process of reaching a decision when faced with an ethical issue. At first the model suggests to pause and think about our response before doing anything. Afterwards, we need to review all the available information we have about the client, their environment, their history etc. and identify possible options. Right after identifying possible options we need to consult the ethics code of our association and see what the ethical guidelines suggest for similar ethical issues. Then, we need to assess the foundational ethical issues and identify any legal concerns. After gathering all these information, we need to reassess the possible options we have and identify a plan of action. When we are sure that the plan of action we identified is the right for the current situations we need to implement it. It is very important, while implementing our plan to keep detailed accounts of the whole process so in the case of any legal or other issues arise will remember why we acted the way we did. The last step of the Ethical Justification model requires by the professional to reflect on the outcome of their decision and see the pros and cons of what we have decided.

Applying the Ethical Justification decision making model

In the case of Sam the main ethical issue is whether I should break confidentiality and inform his parents about his current situation and his refusal to seek treatment or keep confidentiality and try to address these issues during our sessions. Consequently, before making any decision or sharing my concerns with Sam or anyone else I need to pause and think about what the components and parameters of the issue are and how I will act about it.

A good starting point would be to review the information I have up until now about Sam. What I know about Sam is that he is currently studying at our university and he is twenty years old. He told me that he is the only child of his parents and that apart from his aunt who has schizophrenia they do not have another person in their family with a mental illness. He admitted that he has been smoking cannabis for the past two years. After his psychological assessment I could tell that he had a recent psychotic episode. What is more, over the past weeks he has become aggressive and violent towards other people. He refuses to seek treatment other than coming to our sessions and he does not want to inform his parents about his psychotic episode.

One option would be to keep confidentiality as the ethical guidelines suggest and do not say anything to his parents. However, I am very concerned about his behaviour the last few weeks. He seems more aggressive than when he first came into therapy and at times I get the feeling that he loses touch with reality. What makes me seek other options apart from the one of keeping confidentiality is the fact that I am worried that someone might get hurt if Sam has another psychotic episode. Because he has been increasingly aggressive I believe that if he experiences psychotic symptoms in combination with his current violent behaviour it could result in damaging material things or even hurting someone.

Another option would be to keep asking Sam at frequent times about his consent informing his family of his situation. Otherwise, we could talk over therapy the reasons why he does not want to tell his parents about what is happening in his life right now and work it through. Possibly, after he explores the reasons that keep him away from telling his family about what he has been through he will agree to tell them or call them in therapy to tell them together.

Last but not least, is the option of breaking confidentiality without Sam’s consent and letting know about his current situation his parents. This is however, a very difficult decision to make because by taking this option it means that I will lose all trust Sam has on me and our therapeutic relationship. What is more, by breaking confidentiality I am not sure how his parents will react since I do not have a lot of information about their values and beliefs on mental illnesses. I am concern that in the case they do not appear supportive towards Sam it could lead to Sam’s breakdown.

Regarding confidentiality, the British Psychological Society (2009) clearly identifies that psychologists should obtain consent from the clients before disclosing any confidential information. Additionally, the British Psychological Society’s ethical guidelines suggest that the psychologist has to inform the client from the first contact that confidentiality might be limited when the assistance of family members is necessary. What is more, it suggests that breaches of confidentiality should be restricted to the circumstances under which there is sufficient evidence that the client’s or other person’s safety is in danger or the health, safety or welfare of children or vulnerable adults is in danger.

In the case that I will not break confidentiality and Sam goes ahead without treatment there is a chance he will experience another psychotic episode. If he does, and he harms another individual I might have legal consequences because I would have known that there was such possibility and I did not warn anyone. On the other hand, if I breach confidentiality and I inform his parents that he is not engaging into any treatment about his psychotic tendencies then Sam could sue me for breaking confidentiality without his consent. This would also result in me having trouble at the association that I am a member of since breaking confidentiality is not something acceptable by the association when there is strong evidence for harm.

Before taking any decision I will consult a professional colleague so that I will have another opinion in mind. What is more, after putting all the information together by using the ethical decision making problem I would say that at the moment the option I will use is not breaking confidentiality. The reason is that I have not concrete evidence that Sam will actually have another psychotic episode and since his aggression and violent behaviour is not addressed towards a specific person I cannot really know if he is going to hurt someone even if he has a psychotic episode in the future. Nonetheless, I would try and talk with Sam about the reasons behind his decision for not seeking treatment and psychoeducate him about psychosis and drug abuse. Additionally, I will discuss with him about his family situation and how close he feels with his parents. It will be helpful to explore with him the reasons why he is not ready to tell his parents about his current psychological state. Hopefully, by exploring these areas it will be easier for him to seek help and support from his family.

While I will be implementing the aforementioned plan I will make sure I document how I got to the decision of not breaking confidentiality. In the case I will have more evidence that Sam is dangerous to either himself or other I will revisit the ethical decision making model and identify and reassess again my possible options.

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