Importance of Confidentiality in Clinical Psychological Practice

Broadly speaking, it is undoubtedly true that clinical psychologists come across the complexity of human nature through their practice every day. Human thinking and behavior are not something fixed. Biological, psychological and social factors are combined together and by interacting with each other they lead to unique results in clients’ lives. When people enter into therapy, regardless of their mental health issues, their common aim is to eliminate their distress and learn how to cope better with their difficulties. Most times achieving those goals is highly related to the quality of working alliance between the therapist and the client (Lambert & Barley, 2002). Revealing sensitive topics can make the client feel vulnerable and emotionally exposed during therapeutic sessions. Thus, clinical psychologists have the ethical and legal duty to protect clients’ privacy and ensure them that the shared information will remain confidential.

At a first sight, confidentiality may seem a simple and defined issue. However, in real life settings it can be a complex concept to apply to therapeutic context and it is often limited due to a variety of reasons. Some people support the idea that confidentiality is essential to the therapeutic process and the client’s privacy should always be protected, while others argue that sharing information is more important and the confidentiality should be breached under certain circumstances. The purpose of this essay is to critically review these two different perspectives. Stepping back and evaluating these conflicting viewpoints will enable us to formulate a deeper understanding on this controversial issue.

In order to be able to understand the importance of confidentiality in clinical psychological practice, it is crucial to explore the meaning of its definition. The term refers to the therapists’ duty to refrain from sharing clients’ information and keep all the records in a safe place in accordance with legislation and national policies (BPS, 2017). Confidentiality is one of the psychologists’ moral and legal obligations and it is included in the practice guidelines of the British Psychological Society (BPS) and other regulatory documents. According to Woody (1999), confidentiality is “the cornerstone of professionalism” (p.607).

Considering all the above, someone could clearly notice the ethical imperative of confidentiality, which can lead them wondering why it is such a fundamental element of therapy. In order to address this issue, it is really important to interpret confidentiality as a part of the therapeutic process rather that just as a discrete and “one-time” procedure.

Firstly, it is reasonable to assume that confidentiality could lead to higher levels of self-disclose. People who seek support from a therapist may experience a variety of symptoms or situations that they are not comfortable with. As a result, they can frequently feel embarrassed to express their thoughts and feelings (Younggren & Harris, 2008). To put it in other words, without confidentiality, clients may be unwilling to communicate their secrets and deepest beliefs with the therapist or even lie about them to avoid feeling ashamed. In a recent survey, ninety-three percent of participants admitted that they had lied to their therapist (Blanchard &Farber, 2016). Among other reasons of lying, a main one was feeling uncomfortable about the discussed topic. Being dishonest or hiding information can easily lead to poor quality of service and eliminate the positive outcome of the therapy. On the contrary, ensuring them about their privacy and maintaining confidentiality can help them feel safe enabling them to reveal more information. Indeed, there is some evidence that supports this point of view. According to Woods and McNamara (1980, receiving from the therapist the promise of confidentiality can affect the client’s level of disclosure. Additionally, in a more recent work, researchers concluded that confidentiality is one of the main factors that contribute to the clients’ willingness to be open up (Ignatius & Kokkonen, 2007).

Moreover, a lot of academic discussion has been done regarding to how confidentiality is related to the effectiveness of clinical practice, with many professionals arguing that confidentiality is essential in effective psychotherapy (Kobocow McGuire & Blau, 1983). Discussing about confidentiality and giving consent is the first step of building a trust relationship. In a qualitative analysis, that aimed to explore clinical psychology service users’ experience on confidentiality and informed consent, it was shown that all participants related their experience to the quality of the relationship they had developed with their therapist (Martindale, Chambers & Thompson, 2009). Reassuring clients that therapy is a safe place, where they can make their confessions without fear, will possibly lead to a strong therapeutic alliance. A strong therapist-client alliance in turn can affect the outcome of the therapy (Ardito & Rabellino, 2011). Having all the above in mind, it is relatively easy to address the question why confidentiality should be protected in any possible way.

Discussing clients’ records, outside the therapeutic context and without their consent, may harm them in multiple ways and provoke a big trust “rift” between the therapist and the client. On the other hand, under certain circumstances disclosure of information seems the only possible solution. The main reasons for this action are: to maximize the quality of service for the clients, to safeguard the clients or others and to attest in a court (BPS, 2017, p.58-62). Either way, if sharing information is required, clients should be informed about it and give their consent whenever it is possible.

Many times psychologists have to communicate the client’s information to third parties in order to facilitate care and promote the client’s well-being. This can mainly happen in three different situations: supervision, working in multidisciplinary health care teams, and informing family and carers.

Throughout therapeutic process, psychologists may come across a wide range of dilemmas, which can make them feel uncertain about how to handle the situation or what treatment to choose. Supervision addresses these issues giving the opportunity to the clinical practitioner to reflect on their cases and get advice, feedback and guidance whenever it is necessary. Indeed, evidence demonstrates that supervision in clinical practise addresses issues that are considered central for the positive outcome in psychotherapy (Weck, Kaufmann & Witthöft, 2017). Being supervised by someone with the right competences can make the practitioner feel confident, reduce the risk of bias and improve the quality of therapy. Certainly, during supervision sessions the shared information should be anonymous.

In the other two situations the information cannot be anonymous, but the information shared should be limited and focus on how to improve clients’ life. In multidisciplinary health care teams, professionals work together to achieve a mutual goal. In order to contribute to this goal, psychologists may have to share clients’ records with their team (Van Liew, 2012). For instance, a diabetes clinic may have an endocrinologist, a dietician and a clinical psychologist who work independently with the client. However, they will also collaborate with each other sharing client’s information. This will enable them to follow an integrated approach and achieve the best results. Psychological factors can have a great impact on physical health, thus, not sharing clients’ information could lead to poorer quality of services.

Lastly, psychologists may communicate information with family or carers. Many times people who come to therapy are not independent or need help from others to manage their everyday life activities. Children or vulnerable adults may have an environment with a supportive interest in the therapy (BPS, 2017). Sharing specific information can have a positive impact on clients’ life. A good illustration of this would be an elderly with dementia, who may have a maladaptive behavior due to their inability to communicate their needs efficiently. Informing the carers or family about the reasons behind this behavior and guiding them to make suitable adaptations, psychologists can give a solution to a chronic problem and make a positive change to their client’s life. However, the client should be informed about who will have access to their information and give their consent. Observing all the above, it becomes apparent that under some situations discuss clients’ information with others can be beneficial and enhance people’s health.

Except for promoting clients’ well-being, another important reason for breaching confidentiality is safeguarding the client or others. The term of “safeguarding” means protecting someone’s rights and wellbeing (Care Quality Commission). There is a wide spectrum of abusive behaviours, which can violate human rights and cause harm or even death. During psychotherapy, people may confess a behavior or a situation that can put them or others at risk or even be life-threatening. For example, if a child is being neglected or abused, the psychologist has the ethical duty to take on all the proper actions to prevent maltreatment and promote their welfare (BPS, 2017, p.39). Additionally, some people who attend therapy have suicidal ideations. Their psychologists should observe their behavior and weight up their clients’ privacy against their protection. In case they decide that there is a high risk, it is necessary to break confidentiality to prevent them from committing suicide.

Finally, psychologists may share some of their clients’ information, when they are asked to testify in court. Revealing information to the court can light blind spots of a case and affect the outcome of a trial. Before disclosure, it is necessary to inform clients and ask for their permission. However, in cases that a psychologist is instructed by the court, they should inform all the people involved that they cannot offer confidentiality (BPS, 2017,p.61).

All the above situations demonstrate that under certain circumstances sharing information can enhance welfare and minimize the risk of harm for the client and others. Nevertheless, many argue that shifting the attention from the confidentiality as primary obligation to managing risks can lead “…to the dilution of the importance of confidentiality as an ethical imperative” (Donner et al., 2008). The complex nature of human issues complicates things and makes it hard for psychologists to have a stable pattern that they can follow. The decision to disclose confidential material should never be an easy choice. The issues that psychologists consider before revealing any of their clients’ information are numerous and they do not usually have a clear and prearranged answer. Informing their clients about the limits of confidentiality at the initial session and explaining to them in which situations their information may be shared, to whom and how, can help them overcome challenges that can occur during therapeutic process. Another core issue they should think about is consent (BPS, 2017).It is really important to always inform their client and obtain their consent whenever it is possible. Lastly, an important aspect that they should consider is the necessity of this disclosure. To address this matter it would be useful to predict the outcome of this action and who would benefit from it. Balancing the advantages and disadvantages will enable them to have a clear picture. However, basing their decision on predictions and hypotheses can include further risks. For this reason, it is essential to always be aware of their national practical guidelines and try to focus on facts.

Conclusively, confidentiality is an ethical duty and a fundamental element of clinical practice. Thus, breaching confidentiality should be the last resort. Nevertheless, under certain situations it is important to share information in order to promote the client’s well-being, maximize the effectiveness of the therapy or prevent harm for the client or others. In these cases, the practitioner should always weight up the benefits and the harm of the disclosure. Certainly, proper skills and training are required to be able to balance client’s privacy against managing potential risks and welfare. Due to the nature of this issue, there is a lack of scientific evidence demonstrating the role of confidentiality in clinical practice and further research is needed. Using informed consent and following the practical guidelines of the profession enables therapists to avoid predicaments. However, it is necessary for professionals to take into account clients’ individual characteristics and approach every person considering their specific needs. Outlining the importance of confidentiality and its exceptions in clinical practice help us to understand their unique challenges and formulate a holistic view on confidentiality issues.