Ethical Dilemmas Concerning Confidentiality In Adolescents
Ethics have been at the centre of philosophical debates for millennia. Philosophers have been struggling to devise methods of defining behaviour as being ‘right’ or ‘wrong’, moral or immoral. This concept of ethics has also been applied to the practice of psychology. Ethics in psychology, specifically denote a framework composed of previously defined, professionally endorsed standards which aim to ensure the best interests of those who obtain psychological help as an individual or as a group. Conversely, Ethics also safeguard the interests of those who provide psychological service by allowing for a safe area in their professional practise. Taken together, constitution of ethical standards in the field of psychology serves to enable the progression of the psychology/psychotherapy profession.
However, ethics have always been a grey area for those involved in psychotherapeutic interactions or in psychological testing. Ethical dilemmas almost seem inevitable as at different stages of their professional journey, psychologists are inevitably confronted and troubled by choices between “right versus wrong” and “right versus right”. Ethical issues are often complex, multifaceted, and do not always have unambiguous answers. This is made worse by the fact that professional ethical guidelines tend to vary in the degree of detail and are regulated differently by professional organisations or legal systems in different countries since these ethical guidelines set by the American Psychological Association (APA), which are the guiding light on ethics in psychology, themselves are not uniform and enforceable by law.
While strict compliance to these guidelines is expected and demanded from practitioners and testers in the discipline of psychology, there emerge many scenarios in which two or more ethics may clash against each other. Such situations may be described as ethical dilemmas. Ethical dilemmas are such cases when the psychologists have to act in line with one ethical principle although another right – but perhaps conflicting- principle might also apply.
This essay will be specifically focusing on one of the key ethical principles of psychology- confidentiality. Maintaining confidentiality is well established as a key component of effective psychological care; vital for sustaining trust and a strong therapeutic alliance. As such, confidentiality is emphasised to never be breached unless in very limited, specific types of situations. While variations exist in the conditions given by organisations under which it is appropriate for a psychologist to breach confidentiality, two remain constant. Psychologists are allowed to breach confidentiality if, 1) there is a threat of harm to themselves/ others and generally, 2) if the client is a minor. The clause that confidentiality could be breached if the client is a minor is one that has raised many ethical dilemmas and one that is further elaborated on below.
The following study was conducted in Australia to document and explore Australian psychologists’ cases involving confidentiality dilemmas with adolescent clients, how they responded to these dilemmas and what moral reasoning drove their decision. In the study, 20 participants (psychologists) were asked to recall details of cases of adolescents that posed a confidentiality dilemma for them and anonymised information of these cases was relayed to the administrators through a semi-structured telephonic interview. A total of 23 cases were analysed as some participants relayed information on more than one case.
One of the cases that emerged was of a 15 year-old boy engaging in self harm. The boy’s mother had brought him to the psychologist with concerns of the boy acting out. He was in Grade 2 and had had a history of significant bullying since Grade 2. Self- harm had become evident at the offset but he was no prodded for information. By the second session, he began to voluntarily expose the further extent of his self-harm. He had sniffed glue, stubbed cigarettes on himself, tried to choke himself with a wire, drown himself in a bathtub, asked people to hit him at school and even put a hot glue gun to his skin. He revealed the motivating factor to be the need to feel something and to escape from feeling numb and shut down. He reported that he had no plans or intention regarding suicidal behaviours but he did acknowledge ongoing thoughts regarding increasingly risk-taking behaviour. His mother was generally aware that he had cut himself but was unaware of everything else. The participant placed an option before his/her client. The client was informed that his mother would need to be made aware of the situation because he was a young boy and this was ‘heavy duty stuff’. He was given a week to do so, at the end of which, if the boy’s mother had not been informed, the psychologist herself was to intervene. A week hence, when the psychologist got in touch with his mother, she was pleased to realise that he had informed his mother and clarified the full extent of his condition.
The decisions regarding breach of confidentiality made across the 23 case studies fell into five distinct decision types. 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).
In this specific case, the decision to breach confidentiality was a Type 2 decision which thankfully worked in favour of all parties involved, especially the adolescent client.
There were 2 major considerations made by the participants: (i) to minimize harm to the client and (ii) personal cost. Further, a host of strategies were considered to minimizing potential harm to the client and these fell in the following categories: conducting thorough risk assessments, maintaining the therapeutic alliance, empowering the client, supporting the family, and professional safety. Oftentimes managing the cost of breaching confidentiality was also hard as the participants were faced with sleepless nights, guilt and heavy criticism from their peers.
The above study is a clear indication of 2 things. One, that the disclosure of confidential information is not done lightly. Most well-trained, well-reasoned psychologists make serious considerations before taking drastic steps that could compromise the lives of their clients.
And two, that while previous studies have asked psychologists to indicate whether they would breach or maintain confidentiality or how likely they would be to breach confidentiality in a range of hypothetical circumstances), analysis of the interviews from the current study revealed five distinct decision options that can be conceptualized on a spectrum related to the degree of autonomy that the adolescent client is afforded.
There is yet a lot to understand about morality, about good and bad, and right and wrong. Organisations often provide compensation for faulty decisions taken by practitioners and while these are necessary to ensure that a sense of integrity and justice prevails in practitioners, it is also very important to understand that reaching a final decision about ethical dilemmas entails balancing multiple and conflicting risks that requires high risk assessment skills that can only be developed through practice and a thorough understanding one one’s responsibilities to the client as well as one’s profession. Such a level of understanding can only be brought by ensuring that the therapists and testers of tomorrow are trained and advised on clinical records.
