Disclosures requiring that confidentiality be breached are rare. A little preparation should permit you to focus upon supporting your client through the process, preserving your therapeutic rapport.
In part one, we considered how to react when a breach of confidentiality seems necessary, how to prepare for such an eventuality and what to say to the client.
Now we will consider how to continue your involvement with your client once you have had to breach their confidentiality. We will also consider how to proceed when your decision to breach confidentiality is reached outwith the session, whether independently, directed by your supervisor or required by law (eg: by a court order).
Ending the session
The decision to override confidentiality will usually discontinue a therapy session, but probably not your involvement with the client.
You may be advised that your client is not detainable, not chargeable or that the child protection issue they have raised is already known. This decision is unlikely to occur before the scheduled end of the current session, so you should not assume that the client will be unavailable for their next appointment.
In theory, if you have been clear as to your obligations and the actions you must take, your rapport with your client should be unaffected: their disclosure will have been an informed choice and they will see you as doing your duty (which may have been a relief for them). This has usually been the case for me: the client has agreed with the breach of confidentiality and supported my action.
In practice, the client may still feel aggrieved, or may come to feel differently inbetween sessions, especially if the official response isn’t a positive experience. Whatever your professionâ€”psychologist or physiotherapist, counsellor or chiropractorâ€”it would be advisable to devote some or even all of your next session to discussing the client’s experiences since you last met.
Again in theory, you might expect feedback on your report from the relevant agency. In practice, the client may be your only source of information as to how your report was handled. If your client does not attend their next appointment, don’t assume they don’t wish to see you: they may well be detained in hospital or police custody. Check with the agency to which you made your report, but don’t be surprised if they won’t tell you: they too may have obligations to preserve the client’s confidentiality.
If you are aware that your action will suspend or discontinue your involvement with the client, you should discuss how they may resume contact. As their mind will probably be on other things at this point, this discussion should be as simple and straightforward as possible, e.g. “when you get out of hospital, give me a call”. You can follow this up with your usual discharge information letter: the discussion should address any feeling of abandonment, but the letter should ensure that your words of reassurance can be acted upon.
When the client is absent
It is possible that you may make the decision to breach confidentiality outwith the session, on reflection, if presented with additional information. If you are a physical therapist unacquainted with the clientâ€™s mental health history, you might feel you need to consult a mental health specialist before making your call.
If you have prepared the ground, the client will know that you may be required to breach confidentiality and should also know that you are seeking advice as to whether this will be necessary. That you have disclosed their information should not then come as a surprise (or shock) to the client.
You may wish to advise the client of your decision, once reached. As the client is no longer in your presence, you should not be held responsible for their actions while you sought advice. However, it isn’t hard to imagine that your call to advise the client might be construed as a warning by the police or social services. If you don’t wish to be charged with obstructing the course of justice, seek the permission of the officer or social worker to whom you make your report before you contact the client.
If you have not prepared the ground for your disclosure, you may now regret it. If a client has disclosed information to you on the assumption that confidentiality is absolute, they may be disappointed, shocked or angered to discover that you have betrayed their confidence. True, they could react similarly in your presence, even if you have prepared the ground, but in this worst case scenario you may not be able to respond to their reaction for days or weeks, assuming that they ever attend another appointment with you.
Directed by supervisor
Trainees and junior staff may find themselves being directed to break confidentiality by a trainer or supervisor: a disclosure which did not seem significant to you may ring alarm bells for someone with more experience.
Again, your client should be aware that confidentiality is limited, but in this case you probably won’t have been able to prepare the client for this specific disclosure. You should not be left to manage the disclosure and the client’s reaction yourself: a good move might be for your supervisor to be present at the next meeting (if any) to explain their decision and take the brunt of any negative response.
If this sounds disempowering for you, consider that you’re in a learning situation and that these circumstances are actually pretty rare: take the opportunity to watch a more experienced therapist handle such a situation before you have to deal with one alone!
Problems may arise if you disagree with your trainer or supervisor’s decision. Most training contracts are written on the basis that your supervisor is ultimately responsible for your caseload: your clients are really theirs. You should hopefully be able to discuss any such disagreement with your supervisor but, if you do not have such a good working relationship, you may wish to clarify your exact responsibilities and rights regarding your clients: your training course, employer or professional body should be able to advise you.
Required by law
You should be aware that lawyers, courts and other agencies (e.g. police and social services) may request or require that you provide access to your casenotes. This is almost certain to breach the client’s confidentiality, although the consequences will vary greatly from case to case.
Both your professional body and your employing organisation should have guidance as to your responsibilities in such cases but, ultimately, a court can insist that you hand over your notes or face charges yourself.
In such circumstances, you will usually have plenty of time to seek professional and even legal advice as to your position. Organisations’ legal departments exist, in part, to guide staff in such circumstances, although it is as well to remember that their first responsibility is to your employer, not to you.
The important point here is to be aware that your casenotes may be requested by a court long after you have moved on to another job and that, if you are not contactable, a colleague may be required to manage matters in your stead. You should write your notes on the basis that they may one day be read out in court: if you wouldn’t swear to it, think again before you write it.