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Download by: [b-on: Biblioteca do conhecimento online UAC] Date: 12 April 2016, At: 08:33
Ethics & Behavior
ISSN: 1050-8422 (Print) 1532-7019 (Online) Journal homepage: http://www.tandfonline.com/loi/hebh20
Ethical Dilemmas of Confidentiality WithAdolescent Clients: Case Studies FromPsychologists
Rony E. Duncan, Annette C. Hall & Ann Knowles
To cite this article: Rony E. Duncan, Annette C. Hall & Ann Knowles (2015) Ethical Dilemmas of
Confidentiality With Adolescent Clients: Case Studies From Psychologists, Ethics & Behavior,25:3, 197-221, DOI: 10.1080/10508422.2014.923314
To link to this article: http://dx.doi.org/10.1080/10508422.2014.923314
Accepted author version posted online: 11 Jun 2014.Published online: 25 Sep 2014.
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ETHICS & BEHAVIOR, 25(3), 197–221
Copyright © 2015 Taylor & Francis Group, LLC
ISSN: 1050-8422 print / 1532-7019 online
DOI: 10.1080/10508422.2014.923314
Ethical Dilemmas of Confidentiality With AdolescentClients: Case Studies From Psychologists
Rony E. Duncan
Centre for Adolescent Health
Murdoch Childrens Research Institute, Royal Children’s Hospital
Department of Paediatrics
The University of Melbourne
Annette C. Hall
Centre for Adolescent Health
Murdoch Childrens Research Institute, Royal Children’s Hospital
Ann Knowles
Department of Psychological Science
Swinburne University of Technology
Navigating limits to confidentiality with adolescent clients can be ethically and professionally
challenging. This study follows on from a previous quantitative survey of psychologists about con-
fidentiality dilemmas with adolescents. The current study used qualitative methods to explore such
dilemmas in greater depth. Twenty Australian psychologists were interviewed and asked to describe
an ethically challenging past case. Cases were then used to facilitate discussion about the decision–
making process and outcomes. Interviews were transcribed and analyzed using interpretive content
and thematic analysis. Three key findings are discussed. First, it is of little use to perceive confiden-
tiality dilemmas as binary choices (breach/don’t breach) because psychologists described 5 distinct
options. These can be conceptualized on a spectrum of varying degrees of client autonomy, rang-
ing from “no disclosure” (highest client autonomy) to “disclosure without the client’s knowledge or
consent” (lowest client autonomy). Second, confidentiality dilemmas often involve balancing multi-
ple and conflicting risks regarding both immediate and future harm. Third, a range of strategies areemployed by psychologists to minimize potential harms when disclosing information. These are pri-
marily aimed at maintaining the therapeutic relationship and empowering clients. These findings and
the case studies described provide a valuable resource for teaching and professional development.
Keywords: adolescent, ethics, confidentiality, minors, privacy, parents, psychology, psychiatry
Correspondence should be addressed to Ann Knowles, Associate Professor, School of Health Sciences, Swinburne
University of Technology, John Street, Hawthorn, Victoria, 3122 Australia. E-mail: aknowles@swin.edu.au
mailto:aknowles@swin.edu.aumailto:aknowles@swin.edu.au
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198 DUNCAN, HALL, KNOWLES
Jay Giedd (2008), a psychiatrist and international expert in the field of neuroimaging, has
described adolescence as “a time of great risk and great opportunity” (p. 341). Adolescents dif-
fer from both children and adults in their physical, psychological, and social functioning. Theyhave distinct capacities, priorities, and previous life experiences and as a consequence of this
they require a unique therapeutic approach. Working with adolescents in a psychological setting
holds significant potential for impacting positively on their psychosocial trajectory in an endur-
ing way. However, the high potential for risk that also accompanies this life stage increases the
complexity of psychological work considerably. This is particularly true in relation to the ethical
principle of confidentiality. The current study follows on from a previous quantitative survey of
Australian psychologists about confidentiality dilemmas with adolescent clients. The purpose of
the current study was to use qualitative methodology to explore these ethical dilemmas in greater
detail.
The principle of confidentiality might initially appear relatively simple. Maintaining confiden-tiality is well established as a key component of effective psychological care; vital for sustaining
trust and a strong therapeutic alliance (Gustafson, 1997; Isaacs & Stone, 1999; Kobocow,
McGuire, & Blau, 1983; McCurdy & Murray, 2003; Sealander, Schwiebert, Oren, & Weekley,
1999; Sharkin, 1995). Professional codes of ethics are also explicit about the importance of con-
fidentiality, listing only a small number of specific circumstances in which confidentiality may be
breached (American Psychological Association, 2010; Australian Psychological Society [APS],
2007; British Psychological Society, 2009). The APS (2007) describes four distinct conditions
under which it is appropriate for psychologists to “disclose confidential information obtained
in the course of their provision of psychological services” (p. 15): (a) when the client (or legal
proxy) provides consent, (b) when there is a legal obligation to do so, (c) when there is “an imme-
diate and specified risk of harm to an identifiable person or persons” (p. 15) that can be avertedonly through disclosure, and (d) when consulting with colleagues or in the course of professional
supervision. However, despite the consistency of current guidance, previous research indicates
that psychologists are challenged by the practice of confidentiality (Kampf, McSherry, Thomas,
& Abrahams, 2008; Younggren & Harris, 2008), suggesting that managing confidentiality is far
from simple.
The APS has also developed a set of guidelines specifically about working with young people.
These guidelines reiterate the limits to confidentiality contained within the APS code of ethics
and emphasize that a psychologist has a duty to maintain a young person’s confidentiality and
to limit any disclosure in accordance with the express wishes of the young person, unless there
is a clear risk to the young person or to others (APS, 2014). The guidelines also note that when
involved in decisions about whether to disclose a young person’s information, the young person’s
best interests should be paramount and the young person’s wishes should be respected where
possible.
All Australian states provide for confidential and anonymous reporting of suspected child
neglect and abuse where there are reasonable grounds for this belief. However, registered psy-
chologists are not legally mandated to report child abuse in all states. The Australian ethics code
requires psychologists to be aware of legal and organizational requirements for reporting child
abuse and requires that wherever possible clients are informed of the psychologist’s legal and
organizational obligations.
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ETHICAL DILEMMAS OF CONFIDENTIALITY 199
ADOLESCENT DEVELOPMENT
Globally, the life phase of adolescence is gaining increasing recognition as a pivotal stage inthe biological, psychological and social development of individuals. In 1968 the Society for
Adolescent Health and Medicine was founded, and today this society comprises an international
membership (http://www.adolescenthealth.org/ ). Publication of the United Nations Convention
on the Rights of the Child in 1989 was another important step toward acknowledging adolescents’
rights as it attributed the rights within the convention to all individuals younger than 18 years of
age (United Nations High Commissioner for Human Rights, 1989). In 2007 The Lancet, which
is recognized as one of the world’s most prestigious medical journals, devoted an entire issue to
the topic of adolescent health for the first time in its 190-year history (Kleinert, 2007). In 2012 it
did so again (Editorial, 2012). Theoretical and empirical interest in the life stage of adolescence
is greater than ever before.One of the most exciting developments in understanding adolescent development over recent
years has been the emergence of MRI data about brain development (McAnarney, 2008). This
has demonstrated that the brain can be subtly remodelled in response to social, emotional, and
behavioral exposure during adolescence (Sawyer et al., 2012, p. 1633). MRI studies also indicate
that the frontal lobe, which is associated with executive functions such as impulse control, deci-
sion making, emotional regulation, and consequential thinking, is one of the last parts of the brain
to mature (Giedd, 2008; Sawyer et al., 2012). This area of the brain continues developing until
individuals reach their mid-20s. In contrast, the limbic system, which is responsible for pleasure
seeking and appetite, develops earlier in adolescence, meaning that in the early and middle parts
of adolescence there is a significant mismatch between these two systems. This is thought to help
explain increases in risk-taking behavior during adolescence, where disconnect occurs betweenadolescents’ affective drives and their ability to rationally regulate these drives (Giedd, 2008;
Sawyer et al., 2012; Steinberg, 2005).
The way in which adolescents’ capacities for planning, judgment, and decision making emerge
also depends on the social and emotional circumstances in which these are enacted (Steinberg,
2005). When making decisions, adolescents are more influenced by exciting and stressful cir-
cumstances than adults, and this is especially true when they are accompanied by peers (Sawyer
et al., 2012). Research continues to demonstrate that little difference exists between adoles-
cents 15 to 16 years of age and adults in relation to capacities for logical reasoning (Grisso
et al., 2003; Grisso & Vierling, 1978; Gustafson & McNamara, 1987; Hale, 1990; Kail, 1997;
Weithorn & Campbell, 1982) but that psychosocial characteristics such as impulse control and
sensation seeking differ, not reaching maturity until early adulthood (Cauffman & Steinberg,
2000; Scott, Reppucci, & Woolard, 1995; Steinberg & Cauffman, 1996). Several authors have
therefore argued that from roughly age 16, adolescents share the same capacities for logic as
adults yet are more influenced by social and emotional cues, which create the differences seen
in actual decision-making outcomes (Cauffman, 1995; Grisso et al., 2003; Martin et al., 2002;
Slovic, 1998; Slovic, 2000; Steinberg, 2004, 2005, 2007, 2008; Steinberg et al., 2008; Steinberg,
Cauffman, Woolard, Graham, & Banich, 2009; Steinberg & Monahan, 2007). The influence of
puberty on behaviour and emotional well-being, as well as propensity for risk-taking, is also
increasingly being recognised (Sawyer et al., 2012; Steinberg, 2005).
http://www.adolescenthealth.org/http://www.adolescenthealth.org/http://www.adolescenthealth.org/http://www.adolescenthealth.org/
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200 DUNCAN, HALL, KNOWLES
CONFIDENTIALITY WITH ADOLESCENTS
A small body of empirical research exists about confidentiality with adolescents in psychologicalpractice. This has demonstrated that when explicit assurances are provided about confidentiality,
adolescents are more likely to disclose sensitive information (Kobocow et al., 1983). A study of
Australian high school students also found that 98% of adolescents believed that confidentiality
with their school counselor was essential or important (Collins & Knowles, 1995). Studies about
confidentiality between other health professionals and adolescents mirror these findings, demon-
strating the importance that adolescents place on confidentiality and the negative implications of
failing to offer confidential care, such as young people choosing to forgo care rather than risking
their parents being informed about private information (Farrant & Watson, 2004; Ford, Millstein,
Halpern-Felsher, & Irwin, 1997; Jones, Purcell, Singh, & Finer, 2005; Reddy, Fleming, & Swain,
2002; Thrall et al., 2000).Research has also been conducted with psychologists and counselors regarding the man-
agement of confidentiality with adolescents. In a survey of American school counselors, less
than 50% agreement was found regarding confidentiality dilemmas (Davis & Michelson, 1994).
In other studies of American school counselors, decisions about confidentiality with minors were
found to be influenced by the adolescent’s age and the degree of dangerousness of the behavior
(Isaacs & Stone, 1999, 2001). A number of studies have also been conducted in America that
aim to determine under which circumstances psychologists or counselors would breach confi-
dentiality with adolescent clients and what factors influence these decisions (Moyer & Sullivan,
2008; Rae, Sullivan, Razo, & De Alba, 2009; Rae, Sullivan, Razo, George, & Ramirez, 2002;
Sullivan & Moyer, 2008; Sullivan, Ramirez, Rae, Razo, & George, 2002). This body of research
demonstrated that as the intensity, duration, and frequency of a risk behavior increases, so toodoes the propensity for breaching confidentiality. Findings also indicated that with the excep-
tion of extremely high-risk scenarios such as a suicide attempt, psychologists, and counselors
disagreed about when a breach of confidentiality was ethical. Two constructs were found to influ-
ence decisions about confidentiality; the negative nature of the behavior and the therapist–client
relationship. An ongoing theme throughout existing literature is the highly complex nature of
managing confidentiality with adolescent clients (Isaacs & Stone, 1999; Lawrence & Kurpius,
2000; McCurdy & Murray, 2003; Milne, 1995).
THE CURRENT STUDY
For the purposes of the current study, adolescents are defined as those between 12 and 17 years of
age. The current study constitutes the second phase of a broader program of research focusing on
confidentiality dilemmas with adolescent clients. In the first phase, 264 Australian psychologists
participated in an online survey in which they were presented with 68 different hypothetical
vignettes about a 15-year-old boy engaging in risk behavior. The vignettes varied according to the
type, intensity, frequency, and duration of the risk behavior, covering six key behavioral domains:
smoking, sexual behavior, drinking, drug use, suicide, and stealing. In response to each vignette,
psychologists were asked to indicate whether they would breach confidentiality to inform parents
about the risk behavior.
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ETHICAL DILEMMAS OF CONFIDENTIALITY 201
The findings from this first phase of research were published in two parts (Duncan, Williams,
& Knowles, 2012, 2013). The first publication reported the underlying constructs influencing
psychologists’ decisions, and the second reported psychologists’ responses to the 68 hypotheti-cal vignettes, that is, whether they would breach confidentiality. Four key constructs influenced
psychologists’ decisions: (a) the negative nature of the behavior, (b) maintaining the therapeutic
relationship, (c) the dangerousness of the risk behavior, and (d) legal protection (Duncan et al.,
2012). Psychologists reached consensus about the need to breach confidentiality in 16% of cases
and consensus about not breaching confidentiality in 41% of cases. In the remaining 43% of cases,
disagreement occurred, suggesting a high degree of variation in opinion about appropriate limits
to confidentiality with adolescents (Duncan et al., 2013). Consensus was defined as 80% agree-
ment (Pope, Tabachnick, & Keith-Spiegel, 1988). However, the vignettes presented in this first
phase of the research were hypothetical and so might differ from the decisions that psychologists
make when faced with real dilemmas.The current study aimed to document and explore Australian psychologists’ cases involv-
ing confidentiality dilemmas with adolescent clients. In gathering detailed accounts of past
cases and analyzing the processes that psychologists undertook in reaching a final decision,
it was hoped that a greater understanding would emerge about (a) the types of cases that
Australian psychologists find ethically challenging and (b) the way in which they manage these
cases. A qualitative methodology was chosen so that detailed subjective accounts from psy-
chologists could be documented and explored in a comprehensive manner through individual
interviews.
METHOD
Participants
In 2009, during the first phase of this program of research, an online survey of 264 Australian
psychologists was conducted. At the end of the survey, participants were asked if they would be
willing to take part in a telephone interview to discuss their experiences and opinions regarding
confidentiality with adolescent clients in more detail. Sixty-five participants indicated they were
happy to be contacted. Of these 65, 30 could not be contacted due to problems with the contact
details they had provided (n = 7), being on extended leave (n = 5), or failing to return calls
regarding the study (n = 18). The remaining 35 participants were contacted and provided witha plain language statement and consent form. Participants were also informed at this time that
during the interview they would be asked to provide details about a past case of theirs involving
a confidentiality dilemma with an adolescent client. All 35 agreed to participate in an interview.
One participant could not think of an appropriate case regarding confidentiality and so withdrew
from the study, and one participant could not be contacted at the scheduled time for the interview
and did not return follow-up calls. After interviewing 22 of these 35 participants, no new themes
emerged indicating data saturation and hence recruitment ceased. One interview was not recorded
properly due to a technical failure and in another interview the case discussed involved an 18-
year-old client, which fell outside our definition of adolescence. Following the exclusion of these
two participants, 20 participant interviews were analyzed.
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202 DUNCAN, HALL, KNOWLES
Materials and Procedure
The current study received ethics approval from a university and hospital Human Research EthicsCommittee. Prior to their interview, participants were asked to reflect on their previous confiden-
tiality dilemmas with adolescent clients and to choose one case they would be willing to discuss in
detail. A time for the interview was then arranged. Interviews were conducted over the telephone
to minimize costs associated with traveling to the several states and territories across Australia in
which participants lived.
A semistructured interview outline was devised. The interview outline incorporated initial
questions about participant demographics, an open-ended request for participants to describe their
chosen case in detail and then a series of more direct prompts to elicit information about their
decision-making processes, the outcomes of the case, and their personal reflections. Throughout
the interviews participants’ responses were reflected and clarified for accurate understanding.Interviews lasted between 41 and 121 min. All interviews were digitally recorded and transcribed
verbatim. Identifying details were removed to protect participants’ identities as well as their
clients’ identities. All participants gave consent to an anonymized version of their case study
being shared in publications or for teaching purposes.
Analysis
Interview transcripts were analyzed by authors RED and ACH in two stages. During the first
stage, interpretive content analysis was used to code and categorize three specific aspects of the
case studies: (a) the type of risk described in the case study, (b) the decision made regarding
confidentiality, and (c) the considerations that influenced the final decision. These three aspectswere selected based on their consistency with the first phase of the research, which focused on
a series of vignettes, the decisions that psychologists would hypothetically make in response to
these, and the considerations that would influence their decision (Duncan et al., 2012; Duncan
et al., 2013). During this first stage of analysis, these specific components of the interview tran-
scripts were identified, categorized, and coded without reviewing other parts of the transcripts
in detail (Downe-Wamboldt, 1992; Graneheim & Lundman, 2004; Hansen, 2006; Rice & Ezzy,
1999; Schamber, 2000). During the second stage of analysis, thematic analysis was employed.
This entailed coding parts of the transcripts that were relevant to the topic of adolescents and
confidentiality more generally, without restrictions on content or preconceived ideas about what
would be most important. During this iterative process, codes were revised and modified sev-
eral times until a final list of discrete and mutually exclusive themes were attained (Creswell,
2014; Hansen, 2006; Rice & Ezzy, 1999). Throughout the analysis process, authors RED and
ACH consulted to discuss categories and emerging themes until consensus was achieved. Both
the interpretive content analysis and thematic analysis were managed using the software program
NVivo (Version 10, QSR International, 2013).
RESULTS
The results are divided into two sections: demographics and case studies. The second section,
describing results from analysis of the case studies, is further divided into two parts to reflect the
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ETHICAL DILEMMAS OF CONFIDENTIALITY 203
interpretive content analysis and thematic analysis. At the end of all quotes a code is listed to
indicate which participant provided the quote (e.g., P#16 refers to participant number 16).
Participant Demographics
The sample comprised 20 psychologists who all had previous experience working with ado-
lescent clients. Of these 20 participants, 19 were registered psychologists and one was a
provisional psychologist. In Australia, psychologists who are undertaking an internship program
or a postgraduate degree in psychology are registered to practice and are known as provisional
psychologists. Once they have completed these qualifications, they are then registered as a psy-
chologist. After completing further training and supervision in an area of practice, for example,
clinical psychology, they may obtain endorsement in this field. Participants were 80% female,
had been working as psychologists for an average of 11 years (range =
1.5–23 years), and had amean age of 44 years (range = 27–66 years). Half of participants worked in private practice, 35%
worked in schools, and 15% worked in other settings, for example, a government department or
juvenile justice setting. Participants were located across Australia in four of the seven states.
Case Studies
The 20 participants were each asked to provide a description of one case study. However, two
participants provided two cases and one participant provided three cases, meaning that 24 sep-
arate case studies were recorded. Consent was provided to report deidentified versions of all of
these case studies except one, leaving 23 case studies for analysis. Participants described their
case studies in significant detail, often referring back to the case and providing additional infor-mation at multiple points during the interview. Direct quotations for each case study are therefore
extensive, and for this reason only five case studies are included here in full.
The five case studies presented here were selected to convey scenarios with both male and
female clients, a range of client ages, and a variety of risks, including two cases in which the
client is at risk from another individual and three cases in which the client’s own behavior is the
source of the risk.
Case A: 12-year-old boy who witnessed domestic violence
I had a primary school child, whose parents had separated. He first presented with disturbed sleep and
appetite and disturbed mood, very teary all the time, school refusal, which was quite out of character.
Initially one parent [mother] had brought the child to me without the other parent’s knowledge and
then through all of the court processes the child was placed with the other parent [father]. In that
context, the child disclosed witnessing quite severe domestic violence. The child was quite distressed
but there was a federal court order in place for the child being with [the father] and the child was
returned to the parent’s care that night but had disclosed they were very fearful of the parent’s reaction
and the parent had told them they weren’t allowed to tell anybody. I usually let people know when
I’m breaking confidentiality, but in this situation I chose not to inform the child because I felt that
informing the child that I was breaking the confidentiality would increase the child’s anxiety because
I wasn’t able to keep the child in my rooms and not to return home that was outside of my control.
So I did contact child protection and make a notification. The positive impact for him in being placed
with his mum were his mood improved, his sleep improved, his appetite improved, he was enjoying
school, he felt safe and all of those things and yeah a huge improvement for him. P#1
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204 DUNCAN, HALL, KNOWLES
Case F: 15-year-old boy engaging in self-harm
So there was a young fella. His mother had concerns about him acting out in school and she outlineda history of bullying that he had been subjected to that had been really significant since Grade 2. He
was now in Year 9. So there was some self-harming that became evident but I didn’t push too hard.
In the second session he’s disclosed the further extent of self-harm. He was sniffing glue, cigarette
burns on his skin by himself. He reported having attempted to choke himself with a rope on three
occasions and of attempting to drown himself in a bath. He’d also spoken about asking people to hit
him at school and stuff like that. Hot glue onto his skin as well. He was able to indicate to me that
the reason he did these things was because he wanted to feel something, to escape from feeling numb
and shut down, he reported no current plans or intention regarding suicidal behaviours however he
acknowledged ongoing thoughts regarding risk taking behaviours. Mum was aware he’d cut himself
before but she wasn’t aware of anything more extreme than that. I’ve indicated to him oh that’s stuff
I’ve got to tell your mum, you know that’s pretty heavy duty stuff and you know your brain’s such a
young precious thing right now and you don’t want to wreck it. He was a smart boy and he knew thathis mum needed to know this stuff as well. He was concerned about how his father would react so I
indicated to him that I’m going to tell mum but the question is when and I’m prepared to give you
some time to tell her. So basically I gave him a week to tell her and I then spoke to her the next week
and she had heard from him. I clarified the extent that he’d reported and it appeared that he’d done a
full disclosure. P#6
Case O: 14-year-old girl having sex with a 17-year-old boy
A 14-year-old who was in an ongoing sexual relationship with a person who was about two and a half
years older than her. She was quite clear that she had been the instigator of the relationship and when
she came to me it had been going on for about six months. Technically, I think he was 17, technically
that was illegal but I certainly didn’t consider reporting it because that would have just devastated her
life and his and I didn’t believe she was a victim in that circumstance. Now other people would have,
and I was breaking the law and I’m aware of that. She was a young girl who had very little support
from her parents and it was a very disruptive chaotic home and she had moved out and moved in,
living most of the time with this young man in a fairly nurturing relationship. She was a fairly out
there kid, she was quite provocative in relationship to a number of the authority figures in the school
and she was on her own in life at 14 and had been for many years I think really. I thought, what’s
the choices, if I reported her and DHS had walked in and taken her out and tried to put her into some
sort of foster or group home she’d have run away and she’d have been on the street and disrupted
everything, it would have destroyed her life. P#15
Case Q: 15-year-old girl involved in a sexting incident
When I was working at the school we had a young girl and she would’ve been about 15. She’d been
seeing this boy for so many weeks and she sent him a text message of herself naked. So this boy has
it on his phone, takes it to school, someone picks up his phone starts going through photos sees this
photo. And so the girl is all distraught, comes to see me as the school psychologist. It doesn’t take
long for the whole school to sort of be aware but I mean the teachers actually at this point had no idea.
So then I guess I was faced with the issue, well do I have to tell, do I tell the parents? Do I tell the
school? And what do we actually do about it? It was difficult because although we’re faced with the
issue of, you know, what’s happening for this child we’re also faced with a legal issue of the photo
and the fact that it can be viewed as child pornography depending on the behaviour of the people that
have possession of the photo. I mean even if she had’ve said ‘no no no you can’t tell anyone’ I still,
I would have just kept talking to her until she was I guess, convinced isn’t the right word that I want
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ETHICAL DILEMMAS OF CONFIDENTIALITY 205
to use, but until she was sure that it was the right decision to make because I felt in that case because
of her age and because of everything else it really was. But in this case she did know something had
to be done and she trusted my judgement for what that would be. I did let the young girl know thatI’m going to have to tell the teachers, I’m going to have to tell her parents and although she was very
upset and petrified of what her mum and dad were going to think she was actually okay with that and
we got mum into the school and we all sat down and had a chat together P#17
Case U: 16-year-old girl being pressured for sex by family member
I had a young woman, 16, who was an international student. She came to me in a state of great distress.
She was staying with a family of cousins and the young man in the family had said he wanted to sleep
with her and she had tried to say no, no, no and he had put the hard word on her and also found that
she had a mobile phone with a boyfriend’s number in it and said that if she didn’t sleep with him he
was going to blow her cover and say that he knew she had a boyfriend and that she had been sleepingwith him and she was a slut. She was terrified. She came in just saying ‘I’m going to kill myself,
there’s nothing I can do.’ It took a few hours to get the story together and we said you’re not going
to kill yourself, we’re going to fix it, this will be alright, you will get through this, you will not be
raped, we will make sure you’re not, but we are going to have to tell people. And then of course she
got absolutely hysterical. She said ‘no, miss, no, don’t say, don’t say, it’ll be terrible, it’ll be worse.’
And I did and it was very difficult. I went firstly to the principal. We decided that she couldn’t go
home and we spent the whole day on it. Together we rang the out of home care people who deal with
international students and they were no help. We rang DHS and they found a place for her to go but
in the course of the conversation the principal said that she felt so frightened that she had thought of
killing herself and they pulled the plug on that and wouldn’t have her. This was five o’clock. We asked
to see the mother in the household. She denied that it was happening, said that her son would in no
way do that. We got an overnight bag and then we were left with nowhere to keep her. So I said tothe principal I would take her home. I wasn’t very comfortable. She ended up staying with me for
three days. The major breach of confidentiality was when we rang her parents back home overseas
and spoke to her father. He came and arranged other accommodation. I met her about four years later
and she said ‘Miss, do you remember me?’ She said ‘Now my parents have come out I’m living with
them and I’m just finishing accountancy and thank you so much.’ P#15
Interpretive Content Analysis
Three aspects of the 23 case studies were coded using interpretive content analysis: (a) the type
of risk, (b) the decision made regarding confidentiality, and (c) the primary consideration that
influenced the decision. Table 1 presents a summary of the 23 case studies, the type of risk
described in each, and to whom the disclosure of information was made, if a disclosure occurred.
The age and gender of the client and the psychologist’s workplace setting are also included. The
mean client age was 14.8 years (range = 12–17), and nine cases involved a male client (39%).
Two cases involved an explicit risk of suicide; seven involved clients who were self-harming; two
involved domestic violence; three involved consensual sexual activity; and the remaining cases
entailed a range of other risks including missing school, sexting, drug taking, threatening others,
and unwanted sex or sexual advances. Half of the clients (50%) were seen by psychologists in
private practice, 45% were seen by psychologists in a school setting, and one client (5%) was
seen in a juvenile justice setting. When disclosures occurred, information was most commonly
shared with the client’s parents, usually the mother. Disclosures were also made to protective
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T A B L E 1
S u m
m a r y o f t h e A g e ,
S e x ,
S e t t i n g , a n d R i s k f o r t h e 2 3 C a s e S t u d i e s P r o v i d e d b y P a r t i c i p a n t s
C a s e
C l i e n t A g e
( Y e a r s )
C l i e n t G e n d
e r
R i s k
S e t t i n g
P e r s o n t o W h o m I n f o r m a t i o n W a s D i s c l o s e d
A
1 2
M a l e
W i t n e s s e d s i g n i fi c a n t d o m e s t i c
v i o l e n c e
P r i v a t e P r a c t i c e
C
h i l d P r o t e c t i o n A g e n c y
B
1 4
M a l e
S e x u a l a b u s e
P r i v a t e P r a c t i c e
T
h e c o u r t
C
1 4
M a l e
V i c t i m o f f a t h e r ’ s p h y s i c a l a b u
s e
S c h o o l
C
h i l d p r o t e c t i o n a g e n c y
D
1 4
M a l e
S e l f - h a r m , s u i c i d a l , t h r e a t t o h a r m f a m i l y
S c h o o l
P
a r e n t s
E
1 4
M a l e
S h a r i n g i n f o r m a t i o n f r o m a s s e s s m e n t
S c h o o l
P
r i n c i p a l
F
1 5
M a l e
E n g a g i n g i n s e l f - h a r m
P r i v a t e P r a c t i c e
C
l i e n t d i s c l o s e d t o m o t h e r
G
1 5
M a l e
T h r e a t e n i n g t o p l a n t b o m b i n s
c h o o l
S c h o o l
T
e a c h e r i n i t i a l l y , t h e n h e a d o f h o u s e a t s c h o o l a n d
m o t h e r
H
1 5
M a l e
B e i n g t a k e n t o c o u r t f o r s t e a l i n
g
S c h o o l
M
o t h e r
I
1 7
M a l e
B r e a c h i n g i n t e r v e n t i o n o r d e r
J u v e n i l e J u s t i c e
P
o l i c e w i t h a p p l i c a t i o n t o c o u r t t o h a v e c l i e n t d e t a i n e d
J
1 3
F e m a l e
B e i n g b u l l i e d a n d s n e a k i n g o u t a t n i g h t
P r i v a t e P r a c t i c e
N
o d i s c l o s u r e
K
1 4
F e m a l e
S e x u a l l y a c t i v e a n d h a d a n a b o
r t i o n
P r i v a t e P r a c t i c e
C
l i e n t d i s c l o s e d t o m o t h e r
L
1 4
F e m a l e
V i c t i m o f e m o t i o n a l a b u s e & s
e l f - h a r m
P r i v a t e P r a c t i c e
M
o t h e r
M
1 4
F e m a l e
E n g a g i n g i n s e l f - h a r m
S c h o o l
N
o d i s c l o s u r e
N
1 4
F e m a l e
C o m b i n i n g b i n g e d r i n k i n g a n d
s e l f - h a r m
S c h o o l
M
o t h e r
O
1 4
F e m a l e
S e x u a l r e l a t i o n s h i p w i t h 1 7 - y e
a r - o l d
S c h o o l
N
o d i s c l o s u r e
P
1 5
F e m a l e
P o t e n t i a l f o r s u i c i d e
P r i v a t e P r a c t i c e
N
o d i s c l o s u r e
Q
1 5
F e m a l e
S e x t i n g i n c i d e n t
S c h o o l
P
a r e n t s a n d s c h o o l ( w e l l - b e i n g c o o r d i n a t o r a n d
p r i n c i p a l )
R
1 6
F e m a l e
M i s s i n g s c h o o l d u e t o I n t e r n e t
a d d i c t i o n
P r i v a t e P r a c t i c e
N
o d i s c l o s u r e
S
1 6
F e m a l e
H a d t a k e n p a r e n t s ’ m e d i c a t i o n
s
P r i v a t e P r a c t i c e
M
o t h e r
T
1 6
F e m a l e
U n s a f e s e x u a l p r a c t i c e s
P r i v a t e P r a c t i c e
N
o d i s c l o s u r e
U
1 6
F e m a l e
B e i n g p r e s s u r e d a n d b u l l i e d f o
r s e x
S c h o o l
P
r i n c i p a l , p r o t e c t i v e s e r v i c e s , r e l a t i v e c l i e n t w a s l i v i n g
w i t h , p a r e n t s ( o v e r s e a s )
V
1 7
F e m a l e
D i s c l o s u r e o f r a p e
P r i v a t e P r a c t i c e
P
a r e n t s
W
1 7
F e m a l e
E n g a g i n g i n s e l f - h a r m
P r i v a t e P r a c t i c e
N
o d i s c l o s u r e
206
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ETHICAL DILEMMAS OF CONFIDENTIALITY 207
services, teachers, school principals, the court, and in one case a family relative. In some cases
more than one of these third parties was informed about the same information.
The decisions made across the 23 case studies fell into five distinct decision types. As demon-strated in Table 2, these can be conceptualized on a spectrum related to the degree of autonomy
that the adolescent client was afforded. At one end of the spectrum is a decision to maintain
confidentiality in full (Decision Type 1), which entails the highest degree of client autonomy.
At the other end of the spectrum is a decision to disclose information to a third party without
the client’s knowledge or the client’s consent (Decision Type 5). This entails the lowest degree
of client autonomy. The three decision types sitting between these two extremes involve varying
degrees of client autonomy: one in which disclosure is enacted by the client (Decision Type 2),
one in which disclosure is enacted by the psychologist with the knowledge and consent of the
client (Decision Type 3), and one in which disclosure is enacted by the psychologist with the
client’s knowledge but without the client’s consent (Decision Type 4).Case O represents the first decision type; where confidentiality is maintained in full:
I certainly didn’t consider reporting it because that would have just devastated her life and his. P#15
Case F represents the second decision type; disclosure by the client, facilitated by strong
encouragement from the psychologist:
So I indicated to him that I’m going to tell mum but the question is when and I’m prepared to give
you some time to tell her. So basically I gave him a week to tell her and I then spoke to her the next
week and she had heard from him. I clarified the extent that he’d reported and it appeared that he’d
done a full disclosure. P#6
Case Q represents the third decision type; disclosure by the psychologist with the client’s consentand knowledge:
I did let the young girl know that I’m going to have to tell the teachers, I’m going to have to tell her
parents and although she was very upset and petrified of what her mum and dad were going to think
she was actually okay with that and we got mum into the school and we all sat down and had a chat
together. P#17
Case U represents the fourth decision type; disclosure with the client’s knowledge but without
the client’s consent:
She said ‘no miss, no don’t say, don’t say it’ll be terrible it’ll be worse’, and I did and it was very
difficult. P#15
Finally, Case A represents the fifth decision type; disclosure without the client’s consent or
knowledge:
I usually let people know when I’m breaking confidentiality, but in this situation I chose not to inform
the child because I felt that informing the child that I was breaking the confidentiality would increase
the child’s anxiety because I wasn’t able to keep the child in my rooms and not to return home that
was outside of my control. So I did contact child protection and make a notification. P#1
Participants used a variety of considerations in reaching their decisions about confidentiality.
In 16 cases, participants balanced multiple primary considerations to reach a final decision, and
in only seven cases did participants describe being able to make their final decision based on one
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T A B L E 2
A S u m m a r y o f t h e D e c i s i o n s M a d e R e
g a r d i n g C o n fi d e n t i a l i t y A c r o s s t h e 2
3 C a s e S t u d i e s
D e c i s i o n T y p e
C a s e
R i s k
1
C o n fi d e n t i a l i t y
M a i n t a i n e d
2
D i s c l o s u r e
b y C l i e n t
W i t h E n c o u r a g e m e n t
F r o m P s y
c h o l o g i s t
3
D i s c l o s u r e b y
P s y c h o l o g i s t W i t h C l i e n t
K n o w l e d g e a n d C l i e n t
C o n s e n t
4
D i s c l o s u r e b y
P s y c h o l o g i s t W i t h C l i e n t
K n o w l e d g e b u t N o t W i t h
C l i e n t C o n s e n t
5
D i s c l o s u r e b y
P s y c h o l o g i s t W i t h o u t
C l i e n t K
n o w l e d g e o r
C l i e n t C o n s e n t
J
B e i n g b u l l i e d a n d s n e a k i n g o u t a t n i g h t
M
E n g a g i n g i n s e l f - h a r m
O
S e x u a l r e l a t i o n s h i p w i t h 1 7 - y e a r -
o l d
P
P o t e n t i a l f o r s u i c i d e
R
M i s s i n g s c h o o l d u e t o I n t e r n e t a d
d i c t i o n
T
U n s a f e s e x u a l p r a c t i c e s
W
E n g a g i n g i n s e l f - h a r m
F
E n g a g i n g i n s e l f - h a r m
K
S e x u a l l y a c t i v e a n d h a d a n a b o r t i o n
B
S e x u a l a b u s e
D
S e l f - h a r m , s u i c i d a l i d e a t i o n , t h r e a t t o
h a r m f a m i l y
G
T h r e a t e n i n g t o p l a n t b o m b i n s c h o o l
L
V i c t i m o f e m o t i o n a l a b u s e & s e l f
- h a r m
Q
S e x t i n g i n c i d e n t
H
B e i n g t a k e n t o c o u r t f o r s t e a l i n g
N
C o m b i n i n g b i n g e d r i n k i n g w i t h
s e l f - h a r m
S
H a d t a k e n p a r e n t ’ s m e d i c a t i o n s
U
B e i n g p r e s s u r e d a n d b u l l i e d f o r s e x
V
D i s c l o s u r e o f r a p e
A
W i t n e s s e d s i g n i fi c a n t d o m e s t i c v i o l e n c e
C
V i c t i m o f f a t h e r ’ s p h y s i c a l a b u s e
E
S h a r i n g i n f o r m a t i o n f r o m a s s e s s m
e n t
I
B r e a c h i n g i n t e r v e n t i o n o r d e r
208
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ETHICAL DILEMMAS OF CONFIDENTIALITY 209
consideration alone. Eleven distinct primary considerations were described by participants; these
are presented in Table 3. Table 4 presents the range of primary considerations that were balanced
in each case.
Thematic Analysis
Two themes emerged from the thematic analysis: strategies for minimizing harm, and personal
costs. Participants described a range of strategies that they employed to minimize the potential
for harm when managing confidentiality with adolescent clients. The strategies fell into five cate-
gories: conducting thorough risk assessments, maintaining the therapeutic alliance, empowering
the client, supporting the family, and professional safety.
Several participants referred to conducting a thorough risk assessment as a vital part of
ensuring they had all the necessary information to make a professional judgment.So you always sort of mentally have a staircase . . . where’s the risk here . . . and that’s how I treat
issues of confidentiality. . . . There’s a staircase and at each stage I’m saying, I’m testing whether or
not this should go further or whether it stays with us. P#10
TABLE 3
Primary Considerations Used by Participants in Deciding Whether to Breach Confidentiality With Their
Adolescent Client
Primary Consideration
No. of
Participants Quote
Immediate risk of harm 11 “That was a really important intervention because she would have been
raped I’m absolutely certain of that” P#15
Best interests of the client 10 “If I can get some change that ends up being a positive outcome for the
young person . . . then I do that.” P#14
Future risk of harm 8 “I was worried that she could be put in that situation . . . where she had
contact with him again.” P#19
Duty of care 6 “As a psychologist I’ve a duty of care to look after young people and
make sure they are safe.” P#14
Likely parental reaction 5 “That’s always a consideration, you know, what risk are you putting the
child at by involving the parents. P#11
Relationship between client
and parent(s)
4 “I hadn’t had contact with them and I didn’t know whether that was a
positive relationship . . . whether that could actually have a negativeoutcome” P#1
Age 3 “I felt in that case because of her age and . . . everything else it really
was . . . just such a huge issue.” P#17
Impact on therapeutic
relationship
2 “If I broke confidentiality she wouldn’t come back for treatment so I
thought that in terms of engaging her in treatment the most important
thing was the confidentiality and assurance.” P#18
Mandatory reporting
guidelines
2 “We were in a position of having to report. . . . We felt that we had no
choice but to ring the authorities.” P#3
Maturity 1 “She was one of those very mature, what we call you know mature
minor you know very independent.” P#16
Client consent for Release
of Information
1 “Then I was contacted with a release of that client . . . to provide
information to the court.” P#2
Note. P# = participant number.
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T A B L E 4
T h e R a n g e o f P r i m a r y C o n s i d e r a t i o n s T h a t W e r e B a l a n c e d i n E a c h C
a s e
C o n s i d e r a t i o n s
C a s e
R i s k
I m m e d i a t e
R
i s k o f
H a r m
B e s t
I n t e r e s t s o f
t h e C l i e n t
F u t u r e
R i s k o f
H a r m
D u t y o f
C a r e
L i k e l y
P a r e n t a l
R e a c t i o n
C l i e n t – P a r e n t
R e l a t i o n s h i p
A g
e
I m p a c t o n
T h e r a p e u t i c
R e l a t i o n s h i p
M a n d a t o r y
R e p o r t i n g
O b l i g a t i o n s M a t u r i t y
C l i e n t
C o n s e n t f o r
R e l e a s e o f
I n f o r m a t i o n
J
B e i n g b u l l i e d a n d s n e a k i n g
o u t a t n i g h t
M
E n g a g i n g i n s e l f - h a r m
O
H a v i n g s e x w i t h
1 7 - y e a r - o l d
P
P o t e n t i a l f o r s u i c i d e
R
M i s s i n g s c h o o l d u e t o
I n t e r n e t a d d i c t i o n
T
U n s a f e s e x u a l p r a c t i c e s
W
E n g a g i n g i n s e l f - h a r m
F
E n g a g i n g i n s e l f - h a r m
K
S e x u a l l y a c t i v e a n d h a d a n
a b o r t i o n
B
S e x u a l a b u s e
D
S e l f - h a r m , s u i c i d a l , p l a n s t o
h a r m f a m i l y
G
T h r e a t e n i n g t o p l a n t b o m b
i n s c h o o l
L
V i c t i m o f b r o t h e r ’ s a b u s e ;
s e l f - h a r m
Q
S e x t i n g i n c i d e n t
H
B e i n g t a k e n t o c o u r t f o r
s t e a l i n g
N
B i n g e d r i n k i n g a n d
s e l f - h a r m
S
H a d t a k e n p a r e n t s ’
m e d i c a t i o n s
U
B e i n g p r e s s u r e d a n d b u l l i e d
f o r s e x
210
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V
D i s c l o s u r e o f r a p e
A
W i t n e s s e d s i g n i fi c a n t
d o m e s t i c v i o l e n c e
C
V i c t i m o f f a t h e r ’ s p h y s i c a l
a b u s e
E
S h a r i n g i n f o r m a t i o n f r o m
a s s e s s m e n t
I
B r e a c h i n g i n t e r v e n t i o n
o r d e r
211
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212 DUNCAN, HALL, KNOWLES
Strategies related to maintaining the therapeutic alliance included discussing limits to confiden-
tiality at the start of therapy and referring back to these when breaches were necessary, openly
discussing the rationale for any breaches, gaining the client’s trust through initial smaller dis-closures, restricting disclosures to those with a clear need to know, and supporting the client
throughout the process of any breaches that occur:
I’d sort of say . . . your information’s private, I’m not going to speak to your mum about everything
that we talk about here, but if I become concerned about stuff and indeed really scared and if you and
I sort of can’t work it out . . . I might have to tell her some things. . . . And I’ll tell you what those
things are before, we’ll sort of talk about it so you’re gonna know what’s gonna happen but that’s
the way I sort of operate. . . . And if he can’t handle that well then obviously we don’t proceed but
that’s sort of generally how it goes then I’ll ask him basically some questions, does that seem clear to
you? Are you okay with that? . . . and then usually they’ll say yes and then we’ll sort of go on from
there. P#6
The way I used to work it . . . I’d pick a little bit and I’d pick somebody I knew they liked. . . . I said
to him at one stage ‘I want to have a chat with your English teacher’ . . . casting it in terms of his
writing, ‘Have you written about any of this stuff?’ . . . ‘Yes I have’ he said, so that gave me the in,
so then I talked to the English teacher and let him see that nothing happened. P#7
Strategies used to empower the client included allowing the client to be involved in decisions
about the timing of the disclosure, what information was shared, and to whom the information was
disclosed. Clients were also often given the opportunity to disclose the information themselves
first or to be present when the psychologist made the disclosure.
Well I went back to what I’d talked about in the first session and said to her well these were the
options, that either we contacted someone from her family and involved them in the plan to keep her
safe or that we might have to go down the mental health avenue as well. . . . And she responded that
yes she would contact a friend so a friend who was I think she was in her thirties, because she didn’t
want me to contact her mum, so a close friend came to the office with her and we finished the session
together, put together a plan in terms of her safety. P#1
I said actually we did speak about confidentiality in the beginning and this is one of those examples
because you are putting yourself at risk and because of these reasons I do need to talk to your mum,
but what I’m prepared to do is give you an opportunity to have a chat with her and then I’ll follow
up with you in a week so that it’s not coming from me. . . . So when I followed up she hadn’t done
it and she pretty well told me that she hated me and that was it and hung up and that was the end of
it, she knew that I was going to follow up which is exactly what I did. So I made an appointment to
meet with mum and then when mum came in she’d already told her, which is what I wanted in the
beginning anyway. P#11
Now do you want me to ring mum about this or do you want me to let your teachers know or will we
just keep it between us. . . . That sort of thing, so I’m a great believer in empowering the students.
P#13
Participants also spoke about strategies they put in place to support the family more broadly, such
as arranging support for parents and modelling positive ways of reacting for parents.
Her initial reaction was going to be to kick the girl out. She felt like she’d already had enough issues
with this girl over time so I did a lot of work around what were the reasons why this girl may have
done what she did and . . . what’s the way to manage this without putting her at further risk of harm.
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ETHICAL DILEMMAS OF CONFIDENTIALITY 213
. . . We also got mum some separate help and support for herself to be able to process what was
happening. P#19
I talked to mum about . . . the issues. . . . I didn’t believe that she needed to be punished or anything
like that obviously mum had to address some stuff with her but I felt that the punishment was enough
the fact that she so didn’t want her mum to know. P#11
Several strategies aimed at professional safety were also used by participants, such as access-
ing supervision, consulting with colleagues, and documenting the situation and decision-making
process thoroughly.
I spent quite a bit of time documenting the pros and cons and weighing up the potential harm one
way or another. P#16
I had two very senior men that I had supervision from, one is one of [city’s] top family and adolescentpsychiatrists, I invited him a number of years before to supervise the counselling group which he did,
so I sought his counsel on this case and also a very senior [city] psychologist who’s been around for
a long time whose work with adolescents and families I respect. P#7
Table 5 presents a list of the strategies used by participants in attempting to minimize the
potential for harm when managing confidentiality with adolescent clients.
TABLE 5
Strategies Employed by Participants for Minimising Harm in Relation to Confidentiality With Adolescent
Clients
Risk assessment • Conducting a thorough risk assessment in order to determine whether
confidentiality might need to be breached
Strategies for maintaining the therapeutic
alliance
• Discuss confidentiality and limits to confidentiality at the start of
therapy
• Refer back to initial explanation of confidentiality
• Openly discuss the rationale for breaching confidentiality with the
client
• Gain trust and confidence through initial smaller disclosures
• Support the client through the breach of confidentiality
• Restrict disclosure to those with a clear need to know
Strategies for empowering the client •
Allow client to be involved in decision about timing of the disclosure• Allow client to be involved in decision about what information is
shared
• Allow client to be involved in decision about who to disclose to
• Provide client with opportunity to disclose to parent(s) themselves
• Provide client with opportunity to be present while psychologist
disclosesa
Strategies for supporting the family • Provide support to parents around disclosure
• Model positive ways of reacting to news for parents
Overarching strategies • Access supervision
• Consult with colleagues
• Document the situation and decision-making process thoroughly
a
Could equally fit under strategies for maintaining the client-therapist relationship.
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214 DUNCAN, HALL, KNOWLES
The second key theme to emerge from the interviews with participants was the personal cost
that managing confidentiality had on them at times. One participant highlighted the particular
challenges of working in private practice:
It’s very difficult when you’re in private practice, like having worked a lot in teams . . . you can
always go and talk to people . . . but when you’re there in the office by yourself . . . you have to work
through that and take the responsibility yourself so it is a bit harder. P#1
Other participants felt worried about whether they had made the right decision:
It was one of those fingers crossed behind backs scenarios which, working with a lot of my
clients I have quite a bit of doing that . . . you know it was touch and go whether I’d done the
right thing. P#16
Some also referred to the stress they experienced:
I had plenty of sleepless nights. P#7
I was really aware even then that I was documenting in the event that I was going to be fronting a
coronial enquiry. P#16
That’s the only time I’ve had a client come home and stay overnight but I was not comfortable with
it but we were caught and I felt, my principal who was male couldn’t really take her. P#15
Confidentiality issues I think are very ah stressful and I think people need to be aware that that’s sort
of part of the process. P#6
Some participants also talked about the criticism they have experienced from their peers aboutdecisions they have made regarding confidentiality with adolescents:
Certainly open to criticism for not having done so and having done so and I’ve been criticised on both
ends. P#15
DISCUSSION
The current study aimed to document and explore Australian psychologists’ ethical dilemmas
involving confidentiality with adolescent clients. Twenty participants took part in semistructured
in-depth interviews, and they provided detailed accounts of 23 past cases in which they had nav-
igated a confidentiality dilemma with an adolescent client. These candid descriptions provide
a unique insight into the complexities associated with managing confidentiality with adoles-
cents. The findings also extend previous research that has been hypothetical in nature as they are
embedded in actual psychological practice. For the first time, the current study therefore provides
information about the broad range of confidentiality dilemmas that Australian psychologists face
with adolescent clients, the key considerations that influence their thinking in response to these
dilemmas, and the variety of decisions that they ultimately make. The study also provides novel
information about the range of strategies that are used to minimize harm when managing confi-
dentiality dilemmas with adolescents and the personal costs that can accompany these dilemmas.
Three key findings are discussed.
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8/18/2019 Duncan Et Al 2015 Ethical Dilemmas of Confidentiality Wit
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