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Chapter 5
Confidentiality and Privileged Communication
FOCUS QUESTIONS
1. What do you think are the key distinctions between the terms “privacy,”
“confidentiality,” and “privileged communication?”
Points instructors may want to make:
2. Some studies have shown that clients are not very concerned about privacy or
confidentiality when they seek counseling services. What do you think about such
findings?
Points instructors may want to make:
3. How would you respond if a client asked to see the notes you have taken related to his
or her counseling sessions?
Points instructors may want to make:
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• Counselors should write notes so that clients and other people can read them without
the counselor feeling uncomfortable.
• Unless counselors believe clients would be harmed from seeing the notes counselors
have written about their counseling sessions, counselors should allow clients to view
their case notes. Conversely, if counselors believe that their clients would be harmed
by viewing their case notes, counselors may ethically refuse to show the notes to
clients. This refusal will be upheld, even under HIPAA rules, if outside mental health
professionals agree.
4. What do you think should happen to clients’ records after they die?
Points instructors may want to make:
IN-CLASS ACTIVITY
Title: Awareness of Exceptions to Confidentiality
Learning
Goal: To clarify students’ understanding of exceptions to confidentiality.
Procedures: Break the class into small groups, with three or four students in each group.
Each group is to list as many exceptions to confidentiality as the members can
recall. Next, group members should discuss their personal experiences with a
specific limit or a particular exception to confidentiality. Students should also
outline an appropriate manner for responding to each situation discussed (If the
students have not yet worked in the field, hypothetical situations can be
discussed.). After 15-20 minutes, regroup for class discussion.
Discussion
Questions: Can you think of any exceptions to confidentiality that have not already been
discussed in this class?
Describe any instance in which your group had difficulty reaching consensus on
appropriate response(s) to a particular situation.
Were there strong reactions to any of the situations your group discussed? If so,
discuss the strong reactions.
Point/Counterpoint (Debate) Topics
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Title: Confidentiality in Couples Counseling
Learning
Goal: To consider the issues involved in keeping secrets when counseling couples.
Procedures: Assign (or allow students to volunteer) 2 groups of students (preferably 3-5
students per group) to each take one of the positions described below and
prepare a 5-minute argument in favor of that position. Have each group present
its argument. Next, allow the groups to confer for 2 minutes and then have each
group present its rebuttal to the other group’s argument. Lastly, have the class
members who served as the audience vote for which side was most persuasive.
Point: If one partner in a relationship reveals a secret to the counselor, in the
absence of the other partner, the counselor should respect the confidentiality of that
revelation if asked.
vs.
Counterpoint: If one partner in a relationship reveals a secret to the counselor, in the
absence of the other partner, the counselor should not promise to keep that secret
from the other partner.
Title: Confidentiality of Minor Clients
Learning
Goal: To consider the pros and cons of confidentiality when counseling minor clients.
Point: Laws and ethical standards should be changed so that counselors can uphold
the confidentiality of minors over the age of 12.
vs.
Counterpoint: The limits on privacy and confidentiality with minors should not be
changed, as parents have the right to know what their children are discussing in
counseling.
OUTSIDE CLASS ACTIVITY
Title: Written Confidentiality Agreement Relative to Counseling Minor Clients
Learning
Goal: To consider specific difficulties or misunderstandings that can arise when
parents demand information and minor clients refuse to authorize the counselor
to provide it, and to formulate an agreement to minimize such
misunderstandings.
Procedures: Prepare a brief confidentiality agreement for use by counselors, their minor
clients, and the parents (or legal guardians) of minors. The agreement should
state in clear, simple language, the manner in which specific types of
information will be handled with regard to confidentiality (i.e., instances in
which certain information will need to be reported to the parent(s)/guardian(s)
and whether such disclosure will be discussed with the minor client
beforehand). Key considerations include: the client’s right to privacy, the right
of the parent(s) or legal guardian(s) to determine what is in the best interest of
their child, and the counselor’s ethical and legal responsibilities.
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Topic for Self-Reflection/Journaling
Topic: Project yourself into your future as a counselor—what types of clients (e.g., minors or
adults, individuals seeking counseling to deal with normal life transitions, or clients
who are chronically and severely mentally ill) will you be working with, and in what
type of setting? Reflect on how you will explain confidentiality to these clients.
What will you tell them, and what points will you emphasize, to ensure that you are
providing your clients with clear and effective explanations?
CASE STUDY
Marcie is a new client, a 22-year-old female who works as a receptionist in a doctor’s
office. She has just revealed to you, during the intake session, that she has recently lost interest in
most activities, has been experiencing fatigue despite sleeping a great deal, and sometimes
wishes she could cease to exist. She mentioned feeling as though she were “on an emotional
roller coaster” during the past year, throughout her on-again, off-again relationship with a 35-
year-old married man. The last breakup with him seemed really final, and Marcie has felt herself
sinking deeper and deeper ever since. When probed further about suicidal ideations, Marcie
admitted that she has considered killing herself, although she is uncertain whether or not she
would actually do it. She said that she is currently in possession of a gun that her friend allowed
her to keep in her home, following a rash of burglaries in the neighborhood, but she doesn’t
know whether she would actually use it. You have consulted with your supervisor, who has
agreed that Marcie should be referred immediately for a psychiatric evaluation and has instructed
you to arrange for Marcie to go directly from your office to a nearby hospital. Marcie told you
that her mother accompanied her to this appointment and is in the waiting room, but she has
emphatically stated that she does not want her mother to know what is going on with her. How
should this sensitive situation be handled?
Case Study Discussion
You should inform Marcie at the very beginning of the intake session, when discussing the
issue of confidentiality, that counselors are mandated by their professional ethics and the law to
protect clients from harming themselves. At this time, you will need to express your concern for
Marcie’s well-being, and explain to her the need for a psychiatric evaluation to ensure her safety
and to determine whether medication or hospital treatment would be appropriate for her at this
time. You will probably need to spend some time talking with Marcie about her refusal to
disclose to her mother that she is feeling depressed and sometimes suicidal, and you should
encourage her to discuss these issues with her mother now (unless Marcie has revealed a sound
reason not to do so). Marcie must be informed that someone will have to take her to the hospital
for evaluation, for her own protection. That individual could be her mother since she is on the
premises, or it could be an official whose job is to see Marcie safely to the hospital (perhaps an
ambulance, but you probably do not need to mention that option at this time). You should
reiterate that confidentiality is waived when disclosure is required to prevent clients from
harming themselves or others, while at the same time reassuring Marcie that only the facts
related to her suicidal ideations and her possession of a gun will be disclosed. You should also
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tell Marcie that it is critical that the gun no longer be in her possession, in light of her suicidal
thoughts, and advise that she give the gun to her mother or some other responsible adult to
ensure that it is safely returned to its owner.
1. How did you feel as you thought about how you would handle this situation?
2. What were your primary ethical and legal concerns related to this case?
3. If you have previously encountered a client who admitted to having suicidal ideations or a
plan to kill himself or herself, how did you handle the situation?
SHORT PAPER OR ORAL CLASS PRESENTATION TOPICS
1. Privileged Communication Statutes of this State Regarding Counseling Relationships
2. Abuse Reporting Laws of this State
3. Suicide Risk Assessment
4. Confidentiality and Non-Suicidal Self-Injury