A Balancing Act

As a clinical psychologist in private practice, I don’t see confidentiality and communication as mutually exclusive. How can we communicate confidential information in a way that protects both our clients and ourselves?

“Confidentiality is a delicate bargain of trust.” Martin Ugwu

I hope through questions and open up possibilities for wider conversations around confidentiality. Tim Johnson (2019) suggests that “It is by asking questions that an individual becomes ethical”.

I share my journey with young clients who have taught me about trust, respect and holding and sharing their voices. Five-year-old twins shared the importance of their words and how to communicate them.

Confidentiality is that agreement between the practitioner and client to provide a safe space where clients can speak freely. It allows people to reveal shames, fears, and secrets, and receive non-judgmental help and support without fear of that information leaving the room. (APA) Therapists who break confidentiality can fall foul with professional boards. Clients could sue them. So the urge to protect confidentiality is strong. We are trained to protect it at all costs.

What if sharing such conversations is in our client’s best interests? Working with high conflict families in distress opened my eyes to the need for more open communication between parties. My aim was to develop the voice of the child and her ability to communicate her needs in a stressful environment. The right to confidentiality and the need for communication are two ends of the see-saw. We need to balance them.

When can confidentiality be unhelpful?

A message to call an attorney, forensic practitioner or facilitator when parties want feedback on therapy, can feel intimidating, intrusive and scary.

Therapists sometimes hide behind confidentiality as a way of protecting themselves. It is easier to say “I can’t disclose anything” when speaking out can make a material difference in the lives of children. Not saying in my view, becomes unethical. When the therapy process focuses solely on the needs of the individual child without taking the wider context into account, useful information can slip through the floorboards. If the individual is changing in therapy but returns to the same environment, what is the impact of this? What shared information could support the therapy process and what might compromise it?

There are times when working collaboratively could enrich the encounter while keeping it safe.

Chloe and Caitlyn’s story (names changed)

Non-identical 4-year-old twin girls identically dressed down to their hair clips and earrings were referred for an emotional assessment. The purpose was to assess their functioning living with chronic parental high conflict. There were numerous allegations between the parents of various wrongdoing, including sexual abuse. Subsequently, they were court-ordered to attend sessions for support and monitoring. I saw them until they were 8 years old when they were referred to a therapist closer to their home.

Both parents experienced longstanding unhelpful interpersonal styles of engaging i.e. personality disorders. The parents’ long hostile relationship changed little in spite of a number of professional interventions. I saw the children on a monthly basis and every 6 months sent a report to the facilitator on any progress and new concerns. This was to support them living with their parents’ ongoing battles while avoiding unnecessary assessments, given the parents’ constant allegations against one another.

I asked myself:

What right do 4-8-year-olds have to confidentiality?

What are their rights to have a voice with both parents?

How can we communicate the voice of the child more accurately in legal processes? What rights do their parents have to information about the therapeutic process?

I was struck by the need for the children to have travelling voices. Their voices heard within the therapy process, often did not travel beyond the walls. I began to feel it was my job to not only amplify their voices but to do so in a way that was ethical, respectful and in their best interests. I felt a responsibility as a professional to advocate in processes that had a direct bearing on their lives. These ideas nudged me from my safe and comfortable traditional position as a therapist with a sole focus on my client, onto a road with a wider view, where the context of therapy influenced the journey.

Guidelines

Everyone needs to know what to expect from the process from the start. Part of our job is to translate the often garbled and chaotic presenting problem parents provide, into an understandable and manageable description of what this problem is and how we are going to go about dealing with it. The more chaotic the presentation, the more important this step.

Here is an example of a letter to parents:

Dear Mr and Mrs Smit ( name changed)

Thank you for approaching me to try and help you understand some of the challenges Caitlyn and Chloe are currently facing. I understood that you experience a long-standing difficult co-parenting relationship characterized by many conflicts about the children. You made me aware that among these were allegations of sexual abuse, physical abuse as well as problems about the general care of the children including schooling, cleanliness, cutting hair and what activities they should be exposed to.

• The emotional assessment for the girls involves:
• Parent interview with both parents (together or separately) - to get relevant background, developmental history, etc 1-2 hours
• Emotional assessment of Caitlyn and Chloe – 2 x 1-hour interviews where they talk about themselves
• Collateral from the school (with your consent) 2x 30 min
• Feedback to parents (together or separately) about findings of the assessment and planning how to move forward. 1-2 hours

Kindly advise if you would like to proceed with the assessment.

I often am surprised when I supervise at how often, even experienced and competent therapists do not explain to the child why they are in therapy and what the purpose is.

The initial interview with the parents includes ensuring that they understand the assessment process, what I will be doing and why. We discuss what they have told their child about coming to see me. If required, I help them craft an explanation for the child.

Trust

All this leads me to the nature of and creation of trust. That’s why I prefaced my talk with Martin Ugwu’s quotation, “Confidentiality is a delicate bargain of trust.” Trust is a firm belief in the reliability, truth, or ability of someone.

I needed to trust:

• That the children had something to say worth weaving into a collaborative process.

• That I would be able to translate/ communicate their needs into other processes.
• That best interest of my young clients was served.

Chloe and Caitlyn were prepared from the start. They could say whatever they wanted to Tannie Janet and she would only tell what we had agreed upon. These children had been assessed multiple times where various professionals had written down their words that had made their way to court and to their parents’ ears. They were understandably distrustful. The girls slowly learned to trust (it took a long time) that I would not disclose anything they said without their consent.

They began to say things like,

“What are you writing down? ”, I told them.

“Daddy doesn’t know we are here.”, I reminded them “Mom and dad know you are here every time because I have told them.

“Dad says he can hear what we say when we are here .” We toured the building, looking out of the window and down the passage.

“Only tell mommy this”. I clarified that I could not do that.

It is common practice to get your client to sign consent for you to speak to another party. When you have a good relationship, your client may say, “Tell them whatever you like or need to.” I am always cautious when I hear this. I prefer to explain what I will be saying and what I won’t be saying. Ask your client: “What you would you like me to say? What would you not like me to say? “Ask yourself: “What do I want to say? What do I need to say?”

We have to consider: What are the effects of what you DO /DO NOT say?

Ideally, the client will participate in the process and have a sense of agency about what will be said; or not said.

Other questions to consider

Who decides what is in the best interest of your client?

Who will you be checking in with (teacher/parents/coach)?

Who will get feedback on the progress?

What feedback will be given?

How it will be given – written (report/email), who will be copied in? If feedback is verbal, who will be present?

Keeping everyone on the same written page.

Remember who your client is and what your role is. Ask yourself, what is my job here? Children have a right to understand the process, as much as they are able. Communicating to the team including the children as they get older, helps make the process visible to them.

I started including parents, children and doctors/teachers (depending on the need) in my correspondence to ensure that all parties were on the same page. While you are building trust you could send the client a draft. “This is what I would like to send. Anything you would like to change or add?”

Writing documents the process. It protects your client and you. We need to learn to write in a way that is respectful, clear i.e. no jargon. Albert Einstein said, “If you can't explain it simply, you don't understand it well enough.”

The twins and I shared many conversations about the telling of what happened in the sessions – what would be told, to whom, how, when. Slowly but surely, they learned to trust. That meant I told them whenever I had a meeting with their parents and asked them, “Is there anything you want me to say to your parents?” I would also tell them when I was writing a report to the facilitator. He became the man helping mom and dad with their disagreements. I asked, “Is there anything you want me to tell the facilitator?” They came to accept this (I had to walk my talk and prove this to them by standing by my words). When they told me things I could say, I wrote them down in front of them and read them back to them. Sometimes they asked to write in my notes, which I allowed as I saw this as a way of taking ownership. Their writings remained part of the file.

Apart from notes and reports, professionals tend to avoid writing more than they need to. Emailing has made writing to multiple parties easy and more accessible. Emailing can be less formal than a report. Check for accuracy, as mistakes or typos to slip through so easily. “Words are the source of misunderstanding” the Little Prince reminds us in Antoine de Saint-Exupéry’s children’s book (1943).

Balancing the See-Saw

I am grateful to the children who brought to my attention through their experiences, the importance of their voices travelling beyond the therapy space. They helped me translate, their experiences and guided me about how to say what they wanted to say.

I learned that confidentiality and transparency are not mutually exclusive, but two sides of the same coin. (Thomas de Maizier). Aristotle and Kant, proposed that unethical behaviour is a consequence of people not thinking about their behaviour.” (Johnson 2019). I learned that questioning established practices can open doors to more effective ways of working.

Confidentiality and Communication? May we achieve this see-saw balance.

Works Consulted

Allen, A & Grisso, T (2014) Ethical principles and the communication of forensic mental health assessments Ethics & Behavior Vol. 24, 6, 2

Allen, K (2012) What is an ethical dilemma? In the new social worker, Spring, Vol. 19, No. 2

American Psychiatric Association www.apa.org

Botha, J (2019) Patient autonomy/informed consent in The Specialist Forum, Jan/Feb de Saint-Exupéry, Antoine (1943) Harcourt, Brace & World, New York

De Jongh, J (2016) Ethics and professionalism WCPPG Workshop, Durbanville

Dresner, S ( 2018) Strong recordkeeping – a strong defence in Casebook Vol. 26 Issue 1

Good therapy Blog (2017) Client Confidentiality https://www.goodtherapy.org/blog/psychpedia/client-confidentiality

Haugaard, C (2016) Narrative Therapy as an ethical practice Journal of Systemic Therapist 35 (1) 1-19

Howarth, G (2019) The explosion of defensive medicine in The Specialist Forum, Jan/Feb

Johnson, T (2019) Magic Maths and Money, the relationship between science and finance Ethics and actuaries: issues and opportunities 17 May 2019

Medical Protection Society, Ethics for all workshops notes 2012, 2015, 2016 Cape Town Convention Centre

Medical Protection Society (2009-2018) Personal correspondence with various legal representatives regarding cases.

Reidbord, S (2019) Some mainstream psychotherapy is called “evidence-based” some is not. But the distinction is arbitrary and often misleading www./therapist/steven-reibord-san-franciso-us

Whitehouse, S (2012) A duty to treat …and to tell? MPS Casebook, January

Janet Bytheway graduated from UWC with a Master’s degree in clinical psychology. She is an accredited FAMAC mediator and has worked in private practice for the last 28 years. She was originally trained in depth psychology (psychodynamic) but 15 years ago she discovered Narrative Therapy and postmodern thinking. This meeting opened the doors to many new ways of working and facilitated working in challenging areas like children living with chronic psychiatric conditions like Bipolar Disorder and their families; adults diagnosed with personality disorders; co-parenting in high conflict situations and doing court-ordered family assessments and interventions. Her special interest is working with children and families.