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.
For UK therapists there are three occasions on which it is mandatory that confidentiality be overridden for the greater good: when the client is a risk to themselves, when the client is a risk to others and when there are children at risk; respectively, the therapist must inform the Responsible Medical Officer, the Police and the Social Services.
Particular services and professions may offer more specific guidance and place additional duties upon therapists, but it is likely that you will encounter at least one, if not all, of these eventualities.
Professional training usually focusses upon making the decision to break confidentiality. The potential for disrupting your rapport with your client tends to be neglected.
How should I react?
When you become aware that you may be entering into a situation where a breach of confidentiality is mandatory, you should consider reminding the client of your responsibilities. Some therapists may fear that such a warning will discourage the disclosure, putting lives at risk. In my experience, anyone offered such a reminder has nevertheless continued with their disclosure.
Professional guidelines generally recommend consultation with a senior colleague unless this would increase the risk inherent in the situation. A colleague was advised by police officers that delaying contact with them while contacting a supervisor was unwise, as the responsibility for any injury occurring during the delay would rest with my colleague, not with the supervisor.
It is unlikely that the person to whom the initial disclosure is made will be the person who decides whether official action (eg: hospitalisation, arrest or child protection) is taken. You should therefore bear in mind that your decision to breach confidentiality may ultimately lead to no action being taken by the relevant service. As always, be clear as to your own aims.
How should I prepare?
It is best to work on the basis that any session may require confidentiality to be broken and to plan accordingly. Murphyâ€™s Law says that what can go wrong, will go wrong: if you arrange appointments outwith normal working hours, you can be sure that is when an emergency will arise. For this reason, trainees should never see clients when a supervisor is unavailable (appropriate cover should be arranged for leave and other absences).
As a minimum, you should know how to contact your supervisor (or a senior colleague), the local police (most stations have a phone number for non-emergency calls) and the duty social worker for your area. In addition, you should have available the phone number for the clientâ€™s GP (or psychiatrist, if applicable). If you are a community worker, you should also have an effective means of communication (a mobile phone is very effective, but only if charged and capable of receiving a signal).
If you are using a consulting room which has no telephone, so that you must leave the room to make your report, you should be clear as to where the client should await you and who will be available in your absence to monitor or support them, if necessary.
You should be aware of your powers under law. It is possible that the client may attempt to leave and you should know whether and how you are empowered to prevent them from leaving, if necessary. If you are not empowered to prevent the client from leaving but someone else is, you should be aware of who they are and how they can be contacted. If you are empowered to prevent your client from leaving, you should have received training in how to do this without endangering either yourself or your client. If someone else is to attend the client while you make â€œthe callâ€, you should be clear as to their powers and training also.
You should ensure that your client is aware of the limits on the confidentiality you can offer from the outset. If your service has literature on these limits, you should be aware of the contents and know whether this information has been provided to the client. Regardless, you should have reminded the client verbally of your obligations at the start of treatment. This ensures that they have made an informed decision to confide in you.
What should I do or say?
Ideally, your client should be aware of your decision to break confidentiality. If you have previously warned your client that confidentiality is limited, you can begin by referring back to this advice and explaining that you now have a responsibility to follow a particular protocol.
If you are at all unclear as to the grounds for your decision, you should then consider explaining them to your client, as your lack of clarity may well reflect a misinterpretation on your part. Even if you think youâ€™re clear, an explanation could pay dividends: if you have misunderstood, it would be best to establish this before you call in the police!
If you must leave the room to make any phone calls, your client should be clear as to why you are leaving, what is likely to happen when you return and, if at all possible, how long you are likely to be (bearing in mind that time passes much more slowly when you are waiting than when you are busy making phone calls).
If you have a phone in the room, you should consider whether you will make & take phone calls with your client present. You may feel more able to speak freely when alone, but permitting the client to hear at least your side of the conversation provides reassurance that you are not misrepresenting their disclosure and again permits them to correct you if you make an error. If you choose to speak in the presence of the client, the person on the other end of the phone should be made aware of this.
Your client may be angry or upset as a consequence of their disclosure or of your actions. Distress is more likely than anger, in my experience, with despair or a sense of relief being much more common than either. You may wish to address these feelings prior to contacting anyone, but you cannot be sure that attempting to do so wonâ€™t exacerbate their unhappiness and create more difficulties, delaying your report. It is likely that whoever you attempt to contact will not be able to respond instantly. You can support your client while you await the response, knowing that assistance is on the way.
To be continued
In part two, 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).