Confidentiality can be defined as the client's guarantee that what occurs in the therapeutic setting remains private and protected. First and foremost, the issue of confidentiality concerns the client's rights to privacy and safety. These rights belong equally to every client you see regardless of age, status or relationship to you or another client. These same rights apply to both verbal and written interactions you have with anyone other than the client.
As a model for confidentiality in the somatic professions, we turn to the profession of psychotherapy where these issues have been examined and developed over many years.11 The ethical guidelines of most helping professions include a statement about confidentiality (with the goal of helping practitioners make ethical decisions regarding confidentiality). Nevertheless, these ethical statements often fall short of satisfactorily defining the parameters of the client's right to confidentiality. As with other ethical questions throughout the book, practitioners may find it challenging to apply confidentiality guidelines in complex situations.
Most people are clear about major confidentiality breaches such as sharing important personal information about a client with a third party, yet subtle situations occur where boundaries are easy to cross. Consider the following scenarios:
A well-known politician comes to you for treatment. Do you think twice about sharing this exciting news with your friends?
Your best friend sends his wife to you for a session. Do you stop and consider if it is appropriate to answer his questions about her session?
You schedule a session with a 13-year-old boy who will be accompanied by his mother. Prior to the session do you think about whether to work with the boy alone or with the mother present?
If you answered "yes" to any of the questions posed in the scenarios, you have already begun to deal ethically with the issue of confidentiality in your work.
Maintaining Confidentiality
Confidentiality guidelines for somatic professions generally state that information shared between client and practitioner during a session remains private. These guidelines are usually further interpreted to mean that client names, details of treatment and information shared by clients during sessions are not discussed by the practitioner with anyone else.
Behind confidentiality issues are two assumptions: that an important and personal relationship exists between client and practitioner, and that trust is an essential element in this relationship. The client who knows that his right to privacy is honored is more likely to develop the trust necessary for a successful, healthy outcome of the therapeutic encounter. For example, it may be very tempting to tell your friends about the well-known politician/athlete/musician/film star who is your client, or to do a little name-dropping at a social function. You might even be tempted to use this client's name or title in your advertising (e.g., "acupuncturist to the mayor!") All of these actions, however, cross the ethical boundary of confidentiality. The mayor, like every client, has the right to privacy about her sessions with you.
If the mayor chooses to tell others that she knows your work, you have gained a valuable referral. You, however, are still bound by the ethics of confidentiality. Her reference to you does not give you permission to discuss her case with others. If you break this ethical policy, even in casual conversation, it looks as though you are trading on a well-known name and you always run the chance that what you have said could get back to your client. If the situation turns out negatively, you may lose not only the client but professional respect as well. If you work with celebrities or public figures and you want to let others know, obtain disclosure permission (preferably in writing) from the client.
All your clients deserve the same confidential treatment you would give the mayor. In the introductory scenarios the spouse asking about his wife is, hopefully unknowingly, asking you to cross an ethical boundary. And though a number of your friends may know you treat each of them, you are not implicitly authorized to say anything about another's session. You can avoid unethical behavior by saying in a light-hearted manner, "You know it's against my policies to discuss anything that happens within a session to anyone. I'm sure [Terry] would enjoy talking with you about her session." Finally, if you trade sessions or otherwise treat a fellow health professional, he too benefits more from your work together if you maintain his privacy and safety.
Limits of Ethical Confidentiality
The limits of confidentiality can be an area of confusion and misinformation on the part of both practitioners and clients. Not all health care relationships are held to be "privileged" relationships. Unlike a psychotherapist, medical or psychological information about the client is not necessarily legally held in confidence by the practitioner. Therefore it is vital that a well-researched and clear policy statement regarding confidentiality be presented and the practitioner discloses any exceptions to absolute confidentiality.
Two major considerations underlie the limits of professional confidentiality: the practitioner's obligations to the law; and the practitioner's obligations to others.
Regarding your obligations to the law: the legal system may have the right to subpoena your client lists or even your client records. Client files contain information so that you can properly work with any given client. Although you want your files to contain accurate and thorough information, your actual treatment records should only include information as it relates to the treatment and not superfluous notes (e.g., refrain from inscribing details about a client's eccentricities or personal relationships).
Some reasons for breaking confidentiality include: there's a clear and imminent danger to the client or another individual; a client discloses an intention to commit a crime; you suspect abuse or neglect of a child, an elderly person, or an incapacitated individual.
Confidentiality and its limits do not exist in black and white terms. When making ethical decisions, practitioners choose among various levels of thinking and functioning. From one vantage, abiding by the law may seem clear-cut; from another vantage, doing what is best for your client may mean questioning the law; from still another vantage, protecting a third party may mean breaking the client's trust. The practitioner must combine knowledge of the situation with a clear understanding of the ethics involved, and temper these with wisdom and experience.
Practitioners may also reveal details of therapy encounters to their supervisors or supervision groups. In these discussions the names of clients are withheld although other pertinent information and treatment particulars may be shared.
Actions That Minimize
Confidentiality ProblemsWhen you tell your clients up front about the limits to the confidentiality of your work together, they are much better able to give informed consent regarding treatment from you. Therefore, early in your professional relationships let your clients know that you hold your work together as confidential, and that you may discuss your work with your supervisor and that legal or ethical obligations may require you to break confidentiality in extreme circumstances.
The practitioner should avoid making unilateral decisions about breaking confidentiality. Even in some of the legal instances described above, if you must make the decision to break confidentiality, you should discuss your decision with the client beforehand. In this way, while the client may not agree with your decision, she is informed of your reasons.
When you want permission to discuss the professional relationship elsewhere, you should have a specific reason for doing so. This reason should be discussed with the client, and the client needs to give specific written consent. For example, you may wish to correspond about the client with another health care provider, or to use details about the client's condition, treatment and outcome in an article or presentation. The client's permission should specify exactly what details, such as name, dates of visit and treatment records he is authorizing you to share, as well as any specific limitations on where, when and how you may share the information.
In general as soon as you perceive a potential problem surrounding confidentiality, the situation should be discussed with the client. When the 13-year-old boy and his mother are in your treatment room together, whatever one shares the other hears and confidentiality between the two of them is implicitly set aside. At the first session these clients should be informed about whether you will work or speak with either of them privately; if so, specify whether you keep what one says to you confidential from the other and what limits you may put on this confidentiality. In this way both son and mother utilize the therapeutic encounter more successfully.
11. M. Corey, G. Corey and P. Callanan, Issues and Ethics in the Helping Professions, 5th ed., (Pacific Grove, CA: International Thomson Publishing Inc., 1998) pp. 16-17.