Abnormal psychology: Confidentiality vs Duty to Warn

essay by cheryl yow



Scenario:
Amanda is suffering from acute post traumatic
stress disorder for the last six months. Three years
back she was a victim of date rape. She did not
report the incident, believed it was an accident,
and moved on. Six months back she had a panic
attack while watching a movie and had to be
helped by friends to return home. She did not
leave her apartment for a week. Her friend
cajoled her to take help.


The social worker, Jane has been working with
her since and it took her months to develop a good
working alliance and earn Amanda’s trust and
 confidence. But yesterday Jane found out that
behind Amanda’s anxiety is rage. She is
expressing her plan to kill her rapist whom she
finds is enjoying life, succeeding in his career and
now planning to get married when he should have
been in prison. In Jane’s assessment, Amanda’s
plan is well thought out. Jane finds herself caught
in her promise of confidentiality
and her duty to warn.




Question:
Discuss the ethical code provided by American psychological
Association (APA) on this subject.




Psychological treatment, by necessity, entails the
disclosure of extremely sensitive, private information.
The significance of confidentiality is reflected in the ethical
and legal obligations to protect the patient’s privacy. A breach
of confidentiality will harm the patient and expose the
psychologist to a malpractice lawsuit. Although psychologists
have to preserve the confidentiality of their patients, there
are circumstances under which this confidentiality may be
breached such as danger to self and others – committing
suicide, homicide or child/wife abuse. How to ethically set
patient confidentiality boundaries – the balance of the
rights of the patient with the responsibilities of protecting
the society is controversial. This essay addresses the issue
of confidentiality in the above situation of Amanda, who is
suffering from acute post traumatic stress disorder, and by
revealing her plan to kill her rapist, placed Jane, her
social worker, in a dilemma. We will look at the American
Psychological Association’s (APA’s) Ethical code in
maintaining confidentiality and in disclosure; and evaluate
the conflicting values of Jane’s duty to protect and her
duty to warn.



The American Psychological Association’s (APA’s) Ethical
Principles of Psychologist and Code of Conduct serve to guide
psychologists toward the highest ideals of their profession.
These ethical principles in the Ethics Code set forth
psychology’s core values and they play a fundamental role in
setting its ethical parameters. In APA’s 4.01 - Maintaining Confidentiality: it states that the ethical responsibility
of psychologists is to safeguard information they receive
in the course of their practice.


The patient, Amanda, has the right to expect all
communications and records pertaining to her case to be
confidential. The real meaning of trust is that one may tell
all from the depth of one’s soul to another confidentially
and believe without doubt, that the information given is safe
unto death. As it had taken Jane months to be able to gain
Amanda’s trust and confidence in a special therapeutic
relationship, breaking that trust would further worsen
Amanda’s condition and expose her to more harm. A patient
must be able to trust the therapist without a second thought
to information being disclosed to his/her personal detriment.
If this assurance of absolute confidentiality is not honoured
and results in broken trust; it will deter future patients
from seeking psychological treatments or therapies.


An ethically exigent issue in the psychology profession is
the principle of confidentiality and the dilemma it causes
in society. This ethical dilemma arises when two of the
values found in the ethical principles conflict. The duty
to warn in APA’s ethical code has created a principled
dilemma for psychological professionals. Jane faces a moral
problem; she has to choose between –the duty to protect
Amanda, her patient or the duty to warn the rapist or
appropriate authorities of the potential danger. This
creates a potential problem for psychologists, who must
adhere to APA ethical standards, which advocate that under
most circumstances psychologists do not disclose
confidential information without the prior consent of the
patient. Thus ‘to maintain patient’s confidentiality’
conflicts with ‘duty to warn’.



In another similar dilemma, John, a psychologist is the
principal investigator for the ‘Assist’ Project, which is to
identify behavioural trends among HIV+ adults in New York
city. Participants were recruited from HIV/AIDS support
groups. One participant tells John that she is having
unprotected sex with her boyfriend and that her boyfriend
does not know about her HIV status. She has no plans to
reveal her condition. Here, the duty to preserve patient
confidentiality clearly conflict with the need to inform
past and present contacts of an HIV-infected patient of
possible exposure to the virus. Under Principle E: Respect
for People's Rights and Dignity, the APA’s Ethics Code
states that psychologists should respect people's rights
and dignity, including their rights to privacy,
confidentiality and autonomy.
(http://www.onlineethics.org/CMS/research/rescases
/gradres/gradresv3/ hivaffect.aspx).
Thus, Jane needs to seriously consider Amanda’s rights,
autonomy and dignity.




Additionally, there are no clear boundaries that
psychologists can determine whether a patient is dangerous
or not. One may say ‘ I am so angry I could kill him now!’.
Is this said in a fit of anger that does not carry any
threat or to what extent will the patient really executes
this perilous action? Since Jane had found out that behind
Amanda’s anxiety is rage she needs to determine to what
extent will Amanda really set out to harm her rapist. It
could depend chiefly on the intensity of Amanda’s rage
and anxiety. We can never be sure how accurate are
therapists are at predicting who will or will not be
dangerous. In a recent shocking local case, where a
70 year-old taxi driver, Mr Ong Kah Chua set MP Seng
Han Thong on fire by pouring a bottle of thinner! Mr Ong
was angry just because he did not received any hongbao.
A neighbour described Mr Ong as a quiet, reserved and
caring man. He only started acting strangely
(ran up and down the corridorfor no apparent reason)
after his wife moved out to live with their son to
babysit their grandchildren. It is inconceivable and
unpredictable how a quiet, reserved man, even if he has
been acting a little strange lately ( don’t most of us act
a little strange at times, even when we are ‘normal’?)
to resort to such a violent action for a ridiculous
reason. Although he has been in and out the Institute of
Mental Health, no warning was given by his therapist.


This issue of confidentiality and disclosure were the
subject of a tragic case known as Tarasoff v. Regents of
the university of California. In 1969, Prosenjit Poddar,
a graduate student, killed a female student, Tatiana
Tarasoff,after she rejected his romantic advances. He was
diagnosed as having paranoid schizophrenia and had confided
in his therapist that he wais going to kill Tarasoff. The
therapist did inform the campus police and Poddar did
assure the police that he would not commit the crime.
However, Tarasoff’s family sued the university and the
therapists, insisting that they should have warned Tarasoff
of the danger. The Tarasoff case has since been used as a
standard for therapists to warn a client’s potential victims.


Consequently, the Supreme Court of California stated ‘The
protective privilege ends where the public peril begins’
in other words, whenever conflicts arise, safety should
receive priority. California law now advocates that a
psychotherapist has a duty to warn a third party only if:
the therapist actually believed that the patient posed a
serious risk of inflicting serious bodily injury upon an
identifiable victim. The California Supreme Court has
also ruled that threats must be specific: Therapist does
not have to warn if the client makes non-specific threats
against non-specific people.
(http://education.ucsb.edu/csbyd/ED165/docs
/ED165-ethics-Oct-2008.pdf).


This limit to confidentiality has since been highlighted
in the APA Ethical Principles of Psychologists and Code
of Conduct – Disclosure 4.05 states (b)
Psychologist may disclose confidential information-
(3) to protect the client/patient, psychologist,
or others from harm (http://www.apa.org/ethics
/code2002. html). This duty to warn refers to the
responsibility of a therapist to breach confidentiality
if a patient or other identifiable person is evidentially
in clear, imminent danger. The therapist must determine the
degree of gravity of the threat and notify the person in
danger and others who are in a position to protect that
person from harm. Psychologists must maintain
confidentiality and discuss limits of confidentiality
at outset. In John’s case (HIV ‘Assist Project) he could
change his informed consent in future research to include
the notification that confidentiality will not be
maintained if participants indicate that they have placed
an identified person at risk of harm.


Jane’s dilemma could now be eased based on the ethical
code of conduct in Disclosure 4.05. She should tell Amanda
the limits of confidentiality before beginning the
counselling sessions. In assessing Amanda, she should
determine the gravity of Amanda’s threat. Jane believed
Amanda’s plan is well thought out and this indicates that
the threat is serious and is not merely said in a fit of
anger. Moreover, the threat of ‘to kill’ is specific: not
to harm or to injure but ‘to kill’. Furthermore, the person
Amanda wants to kill is a specific person - the rapist. The
rapist is now clearly in imminent danger of losing his life.
Endorsed by Disclosure 4.05 Jane would not be accused of
breaching confidentiality, instead she has the
responsibility to warn the potential victim. In doing so
Jane could prevent an imminent tragedy from happening, she
would have saved a life (though the rapist deserved to be
punished but certainly not by death) and prevented
Amanda from being committed to a mental institute or a jail
term or a death sentence!


The debate whether patients with disorder need protection
from society or society needs protection from these patients
is endless. Resolving an ethical dilemma entails identifying
the pertinent values and evaluating those competing values.
There is no single, definite way of thinking about what it
means to be an ethical psychologist. Mental health
professionals must consider both individual and societal
rights and responsibilities. Confidentiality is required to
protect patient’s identity but more importantly is; in order
to protect the patient from committing an imminent
regrettable crime and to protect the potential victim from
a fatal situation; it is inevitable that in honouring the
duty to protect, the discerning psychologist must
serve his or her duty to warn.

(1552 words)




Reference
Barlow David. H. et Durand V. Mark., (2009). Abnormal Psychology, an integrative approach, USA: Wadsworth Cengage Learning

Reethompson .Psychological Therapy and Confidentiality. Retrieved 5 February 2009 http://www.allfreeessays.com/essays/Confidentiality-Mental-Health/6458.html

APA Assembly. Confidentiality, Disclosure, and Protection of Others. Retrieved 5 February 2009
http://www.psych.org/Resources/OfficeofHIVPsychiatry/HIVPolicy/PolicyStatements.aspx

2002 American Psychological Association. Ethical Principles of psychologist. Retrieved 5 February 2009 http://www.apa.org/ethics/code2002.html