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multiple20-Sep-2007ethics/moralitymoviesnob by votes48560.0%


When is it, if ever, ok to break the confidentiality of a therapist-client relationship?

This is a remake of a survey from 1999: There were only 10 responses to that survey, and I would be interested in how people would answer now.

For the sake of this survey, assume the client is a legal adult, not a minor.

18When the therapist believes the client may hurt other adults in the future.
17Believes the client may hurt other children in the future.
14I think it is ok for a therapist to reveal personal information about the client to proper authorities when he/she believes the client may harm his/herself in the future.
9Other answer
7Believes the client has hurt other adults in the past.
7Believes the client has hurt other children in the past.
7Believes the client will perform an illegal activity in the future.
5When a therapist wants to share the case information with other therapists.
5Other circumstance where a therapist should reveal information:
4When a client's insurance company requests personal information about a client from a therapist, for the purpose of determining if treatment is medically necessary.
4I do not think a therapist should ever reveal confidential information about a client, under any circumstances.
3Believes the client has performed an illegal activity in the past.

posted 21-Sep-2007 12:43pm  
I am going to say no, never, because if you trust somebody to tell them anything, that trust should never be broken no matter what it is you have done. I am conflicted with my decision, but I still firmly believe in it. However, in case the client is dead, the therapist should be able to reveal things in case of criminal investigation.
posted 21-Sep-2007 12:46pm  
I think it's ok to reveal information to proper authorities if a therapist believes the client is a harm to either themselves or others in the future. I think that for it to go that far, the client must show that they have some sort of a plan to do something in the near future. I am also ok with sharing information with other therapists (as long as it's to get advice, if it's for any other reason, such as for a study or something, explicit permission from the client must be given). I am also ok with insurance companies requesting the information. I work for a mental health insurance company, and a big part of their managed care is reviewing cases that have used a lot of sessions w/ the therapist to ensure the care given is medically neccessary for the individual.
LindaH Bronze Star Survey Creator
posted 21-Sep-2007 12:48pm  
If the client reveals that they are hurting other people or will hurt other people, I think that's probably the only situation where it's okay.
posted 21-Sep-2007 1:14pm  
I'm going to say never. I especially don't think the authorities should be alarmed if the therapist believes the person in question is a threat to themselves - they should be free to do what they want.
Enheduanna Survey Central Subscriber
posted 21-Sep-2007 2:30pm  
I don't know. The only two I think might be OK is if they're going to hurt another adult or child in the immediate future. But even then, I'm not entirely sure. Thinking about doing something isn't the same as doing it, or attempting to do it. Some potential criminals could really use the therapy, but if they think they're likely to be reported, they won't talk about the things they really need to talk about.
I also think it would be OK for the therapist to share case information with other therapists as long as they get permission from the patient beforehand and don't use the patient's name.
posted 21-Sep-2007 4:33pm  
Its ok if the client either allready committED a crime, or HAS PLANS to-- anything above a mideameador. I don't think its right to break it if he BELIEVES that they will or had. This survey is very vague and I am not sure what its asking. Since we don't live in a police state, therapists shouldn't report supposed crimes unless they are 100% certain that the person has done what they think he/she done, eg a confession. Its also ok to share statistical information on a client if its using only anonymous data. Its should be ok to share info with insurance companies since they're PAYING FOR IT.
romkey Survey Central Gold Subscriber
posted 21-Sep-2007 7:00pm  
When required by law.

Illegal activity is too broad. Shoplifting a stick of gum is illegal activity. Downloading copyrighted music is illegal activity.

Harm is too broad. Some people would consider yelling at someone harm. Suppose someone is beating on his wife - she knows it, he knows it, the therapist knows it, maybe the police know it. He may be going to the therapist in order to get help in controlling his anger. The therapist has every reason there to assume the guy may harm his wife again, though.

I think that it's reasonable to break confidentiality if the therapist has good cause to believe the person is dangerous to himself or to others, for a fairly high level of danger.

It's also vital that the conditions under which the therapist may break confidentiality are spelled out clearly to the person seeking therapy, at the start.
posted 21-Sep-2007 9:28pm  
If the client is planning to hurt someone.
If the client has hurt a child in the past.

Other than that, I don't think they should ever repeat anything a client has told them. In the case of a client planning to hurt someone, I'd think it would be important that it wasn't just something they were thinking about doing, but actually planned on doing. It's okay to think about things, as long as you don't act on them. And, with the hurting children in the past, it would really depend on how they hurt the child.
posted 22-Sep-2007 1:22am  
It most probably varies between your country and mine, however I'd say if it was only relevant to the police in most think able cases .
posted 22-Sep-2007 8:49am  
AAAaaaagghhhhh!!!! I don't know!!!!!!!
If it comes down to preventing future harm, I would think there would have to be a leak.
posted 23-Sep-2007 1:15am  
For sure if the person is going to hurt themselves or some one else- adult or child. If some one says they murdered a person in the past, then yes, tell. If the person admits they abused a child, I don't know. Part of me says yes, part of me says no.
Biggles Bronze Star Survey Creator
posted 23-Sep-2007 8:34pm  
I'm not sure. I would think the justifications must be enshrined in law somewhere, and I imagine they are reasonable. I certainly don't believe in absolute confidentiality. It doesn't really exist in healthcare - when you give your doctor information, you are really giving it to the wider healthcare team, so referring you on to other specialists should not be seen as a breach of confidentiality. I also think it's reasonable to notify the authorities if someone seems likely to harm themselves or others - but I'm uncomfortable with the words "in the future". I would prefer to say "imminently". I'm not sure about the past.

Doctors are different to therapists, but people may be interested in the rules and regulations that they work to.The British General Medical Council (sets the guidelines for UK doctors, and can discipline doctors or prevent them from practicing) says:

"Sharing information in the health care team or with others providing care
10. Most people understand and accept that information must be shared within the health care team in order to provide their care. You should make sure that patients are aware that personal information about them will be shared within the health care team, unless they object, and of the reasons for this. It is particularly important to check that patients understand what will be disclosed if you need to share identifiable information with anyone employed by another organisation or agency who is contributing to their care. You must respect the wishes of any patient who objects to particular information being shared with others providing care, except where this would put others at risk of death or serious harm."

"Disclosures in the public interest

22. Personal information may be disclosed in the public interest, without the patient's consent, and in exceptional cases where patients have withheld consent, where the benefits to an individual or to society of the disclosure outweigh the public and the patient's interest in keeping the information confidential. In all cases where you consider disclosing information without consent from the patient, you must weigh the possible harm (both to the patient, and the overall trust between doctors and patients) against the benefits which are likely to arise from the release of information.

23. Before considering whether a disclosure of personal information 'in the public interest' would be justified, you must be satisfied that identifiable data are necessary for the purpose, or that it is not practicable to anonymise the data. In such cases you should still try to seek patients' consent, unless it is not practicable to do so, for example because:

the patients are not competent to give consent (see paragraphs 28 and 29); or
the records are of such age and/or number that reasonable efforts to trace patients are unlikely to be successful; or
the patient has been, or may be violent; or obtaining consent would undermine the purpose of the disclosure (eg disclosures in relation to crime); or
action must be taken quickly (for example in the detection or control of outbreaks of some communicable diseases) and there is insufficient time to contact patients.
24. In cases where there is a serious risk to the patient or others, disclosures may be justified even where patients have been asked to agree to a disclosure, but have withheld consent (for further advice see paragraph 27).

25. You should inform patients that a disclosure will be made, wherever it is practicable to do so. You must document in the patient's record any steps you have taken to seek or obtain consent and your reasons for disclosing information without consent.

26. Ultimately, the 'public interest' can be determined only by the courts; but the GMC may also require you to justify your actions if a complaint is made about the disclosure of identifiable information without a patient's consent. The potential benefits and harms of disclosures made without consent are also considered by the Patient Information Advisory Group in considering applications for Regulations under the Health and Social Care Act 2001. Disclosures of data covered by a Regulation4 are not in breach of the common law duty of confidentiality.

"Disclosures to protect the patient or others
27. Disclosure of personal information without consent may be justified in the public interest where failure to do so may expose the patient or others to risk of death or serious harm. Where the patient or others are exposed to a risk so serious that it outweighs the patient's privacy interest, you should seek consent to disclosure where practicable. If it is not practicable to seek consent, you should disclose information promptly to an appropriate person or authority. You should generally inform the patient before disclosing the information. If you seek consent and the patient withholds it you should consider the reasons for this, if any are provided by the patient. If you remain of the view that disclosure is necessary to protect a third party from death or serious harm, you should disclose information promptly to an appropriate person or authority. Such situations arise, for example, where a disclosure may assist in the prevention, detection or prosecution of a serious crime, especially crimes against the person, such as abuse of children."

Q1 Should all gun shot wounds be reported?
Yes, gun shot wounds are the result of a serious incident. The police should be told whenever a person has arrived at a hospital with a gun shot wound. At this stage identifying details, such as the patient's name and address, should not usually be disclosed."

Q14 I work with sex offenders who are transferred from prison to hospital during their custodial sentence. A patient has recently been discharged, but I know he does not intend to register his new address with the police, as he is required to do by law. Should I tell the police he has been discharged?
The Sex Offenders Act 1997 requires the offender to register his name and address with the police. However, disclosures without consent are justified when a failure to disclose information may put the patient, or someone else, at risk of death or serious harm. If you believe that the patient poses a risk to others, and you have good reason to believe that he does not intend to notify the police of his address, then disclosure of the patient's discharge would be justified.

Q15 A child in my practice has recently been taken to hospital suffering serious injuries from abuse. His father is now being prosecuted. I've been asked to provide information about the child and her family for a Case Review. I'm the GP to the child's father and he won't give consent to the release of information, what should I do?
Case Reviews are often set up to identify why a child has been seriously harmed, to learn lessons from mistakes and to improve systems and services for children and their families

Where the overall purpose of a review can reasonably be regarded as serving to protect other children from a risk of serious harm, you should co-operate with requests for information, even where the child's family does not consent, or if it is not practicable to ask for their consent. Exceptionally, you may see a good reason not to disclose information; in such cases you should be prepared to explain your decision to the GMC.

Q16 A patient of mine is a doctor; I am concerned that he has a drinking problem which could affect his judgement. It has taken me a long time to get him to admit to any problems, and if I disclose the information to his employer or the GMC now he will probably deny everything and find another doctor.What should I do?
This patient has the same right to good care and to confidentiality as other patients. But, there are times when the safety of others must take precedence. If you are concerned that his problems mean that he is an immediate danger to his own patients, you must tell his employing authority or the GMC straight away. If you think the problem is currently under control, you must encourage him to seek help locally from counselling services set up for doctors or for the public generally. You must monitor his condition and ensure that if the position deteriorates you take immediate action to protect the patients in his care.

Q17 A patient of mine suffers from a serious mental illness. He is often erratic and unstable. I know that he drives, although I have warned him that it is often unsafe for him to do so. He insists that his illness does not affect his judgement as a driver. Should I tell the DVLA?
The DVLA is legally responsible for deciding if a person is medically unfit to drive. The Agency needs to know when driving licence holders have a condition which may now, or in the future, affect their safety as a driver.

Where patients have such conditions you should:

a. Make sure that patients understand that the condition may impair their ability to drive. If a patient is incapable of understanding this advice, for example because of dementia, you should inform the DVLA immediately.

b. Explain to patients that they have a legal duty to inform the DVLA about the condition.

If patients refuse to accept the diagnosis or the effect of the condition on their ability to drive, you can suggest that the patients seek a second opinion, and make appropriate arrangements for the patients to do so. You should advise patients not to drive until the second opinion has been obtained.

If patients continue to drive when they may not be fit to do so, you should make every reasonable effort to persuade them to stop. This may include telling their next of kin, if they agree you may do so.

If you do not manage to persuade patients to stop driving, or you are given or find evidence that a patient is continuing to drive contrary to advice, you should disclose relevant medical information immediately, in confidence, to the medical adviser at the DVLA.

Before giving information to the DVLA you should try to inform the patient of your decision to do so. Once the DVLA has been informed, you should also write to the patient, to confirm that a disclosure has been made.

Sorry - this is a long post, but I thought it was interesting, and relevant.
posted 23-Sep-2007 10:11pm  
Yes it is ok and present danger to him or her yes I do agree
posted 24-Sep-2007 12:36pm  
I think therapists and their clients should make an agreement about such things, before they start. Then, stick to it.
posted 24-Sep-2007 1:39pm  
Here it is I believe the first three answer choices - if you might be in danger of harming yourself, harming SPECIFIC adults or harming SPECIFIC children is possible/probable.

What you have done in the past is not reportable or if there is just a 'general' chance you might harm someone.

Like, hypothetically I can tell a therapist I have molested children and would like to molest more children and the therapist could not say anything. But if I told the therapist I was hot for the little girl next door and was having troulbe containing myself the confidentiality rules wouldn't apply anymore. (FYI, there are no children in my neighborhood in case you thought I was mentioning a real example).

Here I could confess to rape, murder, any other felony and misdemeanor in the past and the therapist could not say anything.

There is a gray area though about therapists talking to each other. I know my most recent therapist talked to other therapists for advice about me in an anonymous sense without revealing my name, etc. I guess they can do this as long as it's kept general.
(reply to bill) posted 24-Sep-2007 1:41pm  
> I think therapists and their clients should make
> an agreement about such things, before they start.
> Then, stick to it.

Here in the beginning they give you a form outlining all the rules and when they can and will report you. You have to sign it before starting therapy.
(reply to cerealkiller) posted 24-Sep-2007 1:50pm  
That seems fair.
(reply to bill) posted 24-Sep-2007 1:54pm  
> That seems fair.

The therapists don't know everything though. I always hit them with things they have get legal advice on before they let me discuss the details. Like, " Do I have to report this or not?"
(reply to cerealkiller) posted 24-Sep-2007 2:03pm  
I noticed that you seem to get off on telling people that you've done bad things, or at least implying that you may have.
(reply to bill) posted 24-Sep-2007 2:18pm  
> I noticed that you seem to get off on telling
> people that you've done bad things, or at least
> implying that you may have.

It's not that actually. It seems to show up more when I'm extra depressed, feeling sad or going through bad times. I'm having a car reposessed this week. I guess that qualifies as a bad time.

I guess the fact that I go beyond the therapists realm of knowledge on reportables means they must not get many patients with major issues like that.

posted 26-Sep-2007 11:07pm  
Court order or law
posted 5-Oct-2007 1:21am  
Only if they make a Lifetime movie about it.
they Survey Central Subscriber
posted 10-Oct-2007 9:11am  
I don't know.
posted 26-Oct-2007 9:13am  
They should be able to report somebody who has already been a danger to other people or who poses a threat to society.
posted 3-Jul-2009 5:48pm  
I understand why a therapist may be required to reveal confidential information. What about when, in an informal situation, someone shares personal information with a non-therapist friend and requests that that information be kept confidential? I understand, again, that if that person reveals information about possible danger to self or others, or about child or elder abuse, confidentiality may be justifiably broken; but if none of those dangers are present, is it ok to break confidentiality? What if breaking confidentiality could put the person at risk of greater danger (as in the case of domestic violence)?
posted 30-Mar-2014 3:56pm  
In the case of possible murder, a horrible crime committed.
posted 4-Apr-2014 10:10am  
The client should sign a waiver, prior to treatment, that allows the therapist to reveal to the appropriate authorities any discussion of plans to harm themselves or others. The therapist should be able to discuss the case with colleagues, but that doesn't require revealing who the subject is. They need to be careful about revealing too many specifics.

I was at a seminar once where someone presented a case study and I recognised the subject because they revealed too many specifics around gender, age, work history, medical history, pets. One needs to be careful.
posted 10-Jul-2014 10:39am  
What if you reveal your fear for your life from a very unstable step kid who's father cannot face the situation. I explained i was going to get a protection dog. By my next appointment, he dropped me after six sessions, i really liked him a lot and am contused what happened - no explanation. I am trying to understand what has happened to our patient/therapist relationship. I am thinking maybe this was a problem for him?

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