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Confidentiality and informed consent in counselling and psychotherapy: a systematic review
Abstract
Ethical behaviour is fundamental to counselling and psychotherapy practice. Two core ethical concepts that transverse all health professions are informed consent for treatment and confidentiality. There are instances where breaches of confidentiality must occur and these need to be clearly articulated to, and be understood, by the client before therapy commences. In counselling and psychotherapy, breaches of confidentiality and the failure to obtain clear consent for therapy are common client complaints. The objective of the current study was to systematically review empirical evidence that examined client understandings of informed consent and/or confidentiality, and to systematically review evidence that examined how therapists obtain informed consent and/or understandings of confidentiality. Academic Search Complete, Informit, PsycARTICLES, Psychology and Behavior Sciences Collection, PsycINFO, and ScienceDirect were searched from January 2007 to May 2017. Studies that contained results relating to client understandings or how therapist obtained informed consent and understandings of confidentiality were included. Seven studies met the inclusion criteria. Client and therapist understandings of confidentiality appear to be context and culture specific. There also appears to be variety in what therapists tell clients that would enable them to give truly informed consent for therapy. No Australian research was located during the search time frame and no studies focused specifically on client understandings or how therapists obtained informed consent and checked for understandings of confidentiality. This neglect suggests research is needed in this area. Whilst the importance of confidentiality and informed consent is widely accepted, actual therapist practice in these areas is unknown.
... The overall assistive focus of the counselling service likewise draws from the confidentiality ethical code that also hinges strongly both on the private and professional nature of the facility (Mitchels & Bond, 2021) [18] . As an invaluable service dimension, the remarkable protection both clients and counsellors enjoy from the confidentiality ethic are critical to the entire counselling interaction, as well as the ultimate achievement of counselling service outcomes (Harwood, Turnock & Ashleigh, 2014; Lamont-Mills, Lamont-Mills, Christensen and Moses, 2018) [14,16] . The professional counselling service dimension in effect aligns with approved professional service conditions, including the need for trust, acceptance, privacy and rapport between the professional and client to achieve worthwhile service outcomes (Getachew & Tekle, 2020; Ahimie, et al., 2020) [11,1] . ...
Students' in-depth knowledge about the counselling service often increases their confidence in the facility. The more service insight students have, the greater their chances of benefitting tremendously from high service commitment that culminates in enhanced service use. The research aimed at exploring students expressed counselling service dimensions, to reveal their awareness and commitment levels to their institutional counselling services. The interpretive phenomenological multiple case study research design, embedded in the qualitative approach guided the study. Data were mobilized from thirteen well-informed participants, purposively and conveniently selected from three southern-based public universities in Ghana. In-depth interviews and a focus group discussion facilitated data-collection, but the Interpretive Phenomenological Approach was employed to reduce and make meaning from the gathered data. The study foremost portrayed counselling as a unique student facility. Further sub-themes projected counselling as a profession with an ethical code that also offers tremendous academic and social life benefits to students. University authorities and counsellors were encouraged to adopt innovative and student-friendly strategies to consistently promote counselling service use among students on the various university campuses. The research essentially confirmed students' profound counselling service awareness, in agreement with significant professional counselling features though consistent awareness-creation will promote service use among students.
... This finding suggests that there was a close relationship between how community-based counsellors view the level of confidentiality held in the school context and how confident they feel in sharing information with their counterparts there. Given that the sharing and exchange of relevant information is critical in schoolcommunity partnership among counsellors and other care professionals (Lamont-Mills et al., 2018;Lim & Wong, 2018;Low, 2019), the current lack of confidence to share information is indeed a concern for all stakeholders involved. This warrants further research as well as practical interventions within schools and in the community to facilitate greater confidence in sharing of information among stakeholders. ...
School counselling is not an isolated school-based intervention but rather as part of a more holistic social wellbeing system where there are many stakeholders. Studies have examined students’, school counsellors’, teachers’, and administrators’ perceptions of school counselling. Research that focuses on the perceptions of community counsellors of school counselling is rare. This paper reports on a quantitative survey study of community counsellors’ perceptions in Singapore. Findings indicate some expectations such as school counsellors could offer some family counselling and perceptions such as confidentiality could be strengthened in schools, were widely held among community counsellors. Findings also suggest deeper understanding of both school and community counsellors’ perceptions is needed to strengthen collaboration for better mental health support for children and youths.
... Ethical patient information is required to provide all the information that is necessary for a patient to make an informed decision concerning a suggested treatment plan (6,(31)(32)(33). In a recent systematic review, Lamont-Mills and colleagues summarized the evidence on the role of confidentiality and informed consent in counselling and psychotherapy (34). They concluded that within clinical practice, psychotherapists apply standardized informed consent templates but they also state that we know only little about the actual adequacy of informed consent obtainment in psychotherapy as well as on the patients' own understanding of informed consent and confidentiality. ...
Objective
The evidence-based practice movement clearly defines the relevant components of a good treatment. In the present article, we elaborate on how the active involvement of patients within psychotherapy can and should be increased in order to respect ethical considerations. Our arguments complement the requirements of evidence-based practice, and are independent of the actual psychotherapeutic treatment approach being used.
Method
Theoretical and ethical analysis.
Results
In order to respect patient autonomy, psychotherapy needs to be transparent and honest when it comes to disclosing the relevant factors for promoting therapeutic change. It has been argued that ethical informed consent needs to include empirically supported patient information. In this paper we go one step further: we outline that fully respecting ethical considerations in psychotherapeutic treatment necessarily calls for acknowledging and strengthening the active role of patients in the course of psychotherapy. Accordingly, patients need not only to be informed openly and transparently about the planned treatment, the treatment rationale, and the expected prognosis of improvement in the course of psychotherapy, but they also need to be actively involved in the decision-making process and during the entire process of psychotherapeutic treatment.
Conclusions
Our arguments support the tendency that can be observed in health care in recent years towards more active patient involvement across different health-care domains, but also in clinical research. This article offers an ethical perspective on the question what defines a ‘good psychotherapy', which, hopefully, will help to leave behind some of the ongoing psychotherapy debates and move the field forward.
... Confidentiality plays a major role in any medical procedure, but especially in psychotherapy [12,13]. Insurance companies should not be informed of any reason a patient may request psychotherapy. ...
Since the beginning of 2018, certain health insurance companies in Switzerland have systematically investigated how so-called delegated psychotherapy is performed in psychiatric practice. Some insurance agencies have also demanded that fees be back-paid when they suspect that a psychiatrist did not personally see a patient but delegated a psychotherapy.
In the current legal frame, delegated psychotherapy should be indicated and monitored by psychiatrists. Insurance companies claim that if psychiatrists have not responsibly and personally examined a patient, the criteria for delegated psychotherapy are not being met. As mentioned previously, some insurers expect a back-payment if they assume delegated psychotherapy is occurring without an examination by a psychiatrist. The obligations of psychiatrists to examine a patient are, however, not explicitly required by the law. Therefore, the main point of dispute is not whether a psychiatrist has personally examined a patient at the beginning of psychotherapy, but how the supervisory role of psychiatrists is defined. Note that several responsibilities will remain within physicians’ expertise (pharmacotherapy, comorbidity analysis, organic disorder diagnosis, etc.) and are not part of this discussion.
Bullying is widely accepted as a significant issue confronting schools across the globe. The potential short and long-term consequences of bullying for involved students include negative academic and mental health impacts. It is known that a whole-school approach is required to effectively manage bullying. As such, school psychologists and counsellors are well-placed to play an important role in the prevention of and response to bullying in their workplace schools. By virtue of their training and skill-set, school psychologists and counsellors could be involved in the training of other staff, educating and collaborating with stakeholders, and counselling the involved students utilising methods such as motivational interviewing. In order for these staff members to play an effective role in bullying prevention and intervention, they require professional development on bullying, a supportive leadership team, and a workplace that provides a clear delineation of their role.
This article examines the identity of the profession, and the demographics of the national workforce of counsellors and psychotherapists in terms of their educational qualifications, age, professional experience, employment status, and geographical location, based on Australian Bureau of Statistics census data and four workforce studies. It provides context for and insight on the future direction of counselling and psychotherapy as a profession, including trends in service provision arising from advances in information and communication technology and time-poor client populations, and the need for PACFA’s training and ethical standards to keep pace in addressing new forms of education and practice enabled by technology.
This article reports on a qualitative study that set out to understand stakeholders' perception of the school counselling service in Singapore. Using semi-structured interviews, this study explored the perceptions of three main stakeholder groups, namely teachers and counsellors working within the schools and those working in the communities. Altogether, 19 interviews were conducted. Two key theme areas were uncovered. First, the stakeholders observed and expected differing levels of confidentiality for information obtained during counselling. This presented a barrier for cooperation between the stakeholders. Second, stakeholders, while keen to ensure students' families were served appropriately, held different ideas of how that could happen. No clear model of collaboration seemed to exist at the time of the study. Implications for practice were discussed.
Studies of psychologist misconduct generally focus on unethical sexual behaviours. In contrast, the following study reports on all complaints by the public against psychologists reported to the New South Wales Psychologists Registration Board over a four year period. There were 248 independent notifications of misconduct about 224 registered psychologists, out of a total sample of 9489 registered psychologists. The most frequent type of misconduct reported was in relation to poor communication standards (35.5%). Other complaints were in relation to professional incompetency (16.5%), poor report writing (14.1%), poor business practices (12.5%), boundary violations (9.7%), poor character (5.6%), registration status (3.2%), impairment (1.6%) and the inappropriate use of specialist titles (1.2%). Males were 2.5 times more likely to have a misconduct complaint made about them than females. Senior highly qualified psychologists attracted a greater number of complaints, but these were generally of a less serious nature. Over a 30 year career, about 20 out of every 100 psychologists can expect to receive a complaint from the public, and 2 will receive a serious misconduct complaint that might lead to deregistration. Strategies for preventing malpractice arising from these results include regular peer consultation, developing quality practice standards, and maintaining professional boundaries.
The Australian Psychological Society Code of Ethics explicitly states that clients are to be informed about the legal limits of confidentiality prior to engaging in any psychological relationship. Maintaining and respecting client confidentiality is also seen as a major professional obligation. Despite this, little research has examined how limits of confidentiality is introduced, discussed, and oriented to in real-life psychological consultations. An initial consultation between a client and a provisionally registered psychologist was used to explore how a psychologist and client interactively managed limits of confidentiality. Using a discursive psychological framework, analysis revealed that while the psychologist complied with the ethical obligation of informing the client of the limits of confidentially before counselling began, the way in which the psychologist enacted this restricted the client’s opportunities to ask questions or seek clarification about these limits. Further, when the psychologist explicitly asked for client confirmation of understanding and acceptance of these limits, what the client confirmed and accepted appears unclear. Given that breaches of confidentiality are Registration Board matters, this lack of clarity and limiting of client interaction is concerning.
This literature review examines the effectiveness of family and relationship therapy and psychotherapy in relation to the following seven of the key modalities.
Experiential Family Therapy (EFT)
Structural Family Therapy (SFT)
Cognitive Behavioural Therapy (CBT)
Multi-systemic Therapy (MST)
Family Problem Solving
Solution Focused Therapy (SFT)
Narrative Therapy
It is acknowledged that these modalities represent only a sample of the many forms of family therapy practiced in Australia and elsewhere. They do represent however some of the key approaches.
This review poses the central research question: ‘To what extent, if any, is family and relationship therapy and psychotherapy effective?’ The review systematically poses this question when examining each of the seven key modalities. The review assumes that the common aim of each of these modalities as they relate to the field of family and relationship therapy is to identify and treat problematic family and intra-personal relationship dynamics, as defined by the client(s). The review also identifies any knowledge gaps pertinent to the research area.
This is the perfect book for any student new to qualitative research. In this exciting and major updating of his bestselling, benchmark text, David Silverman walks the reader through the basics of gathering and analysing qualitative data. David Silverman offers beginners unrivalled hands-on guidance necessary to get the best out of a research methods course or an undergraduate research project. New to the fourth edition: - A new chapter on data analysis dealing with grounded theory, discourse analysis and narrative analysis - Further worked-through examples of different kinds of data and how to interpret them - A separate section on focus groups and interpreting focus group data - An expanded ethics chapter - More coverage of digital media and photographs as data - A companion website with additional case studies and examples, links to SAGE journals online, and links to useful websites, podcasts and Youtube videos. This fourth edition is also accompanied with its own group page on www.methodspace.com where users can give feedback and discuss research issues.Visit www.methodspace.com/group/silverman
Thematic analysis is a poorly demarcated, rarely acknowledged, yet widely used qualitative analytic method within psychology. In this paper, we argue that it offers an accessible and theoretically flexible approach to analysing qualitative data. We outline what thematic analysis is, locating it in relation to other qualitative analytic methods that search for themes or patterns, and in relation to different epistemological and ontological positions. We then provide clear guidelines to those wanting to start thematic analysis, or conduct it in a more deliberate and rigorous way, and consider potential pitfalls in conducting thematic analysis. Finally, we outline the disadvantages and advantages of thematic analysis. We conclude by advocating thematic analysis as a useful and flexible method for qualitative research in and beyond psychology.
Obtaining informed consent from a client to participate in psychotherapy includes providing an understanding of what treatment or evaluation is going to take place with the psychologist, as well as what the psychologist may or may not do with the client's records. Psychologists have an obligation to communicate clearly with their clients regarding informed consent. In this investigation, 1 Health Insurance Portability and Accountability Act Notice of Privacy Practices was solicited from a practicing psychologist in each state plus the District of Columbia. The authors then analyzed these forms using 2 measures of readability. A large majority (82%) of these forms were written at the ceiling reading level (12th grade), and almost the entire sample (94%) fell into the difficult range of reading ease. On the basis of the data obtained in this investigation, it is recommended that psychologists move to improve the readability of these documents and should do so to improve clinical practice, reduce liability, and follow ethical standards. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The aims of this qualitative study were (1) to add to the understanding of the growing field of psychosocial counselling in
Nepal, and (2) gather concrete points for improvement of services. Semi-structured interviews were conducted with clients
(n = 34), para-professional counsellors (n = 26) and managers (n = 23) of organizations in which psychosocial counselling was taking place. The main findings were that stakeholders generally
presented a positive view of the significance and supportive function of psychosocial counselling, while providing useful
suggestions for improvement. Matters of ongoing training and supervision, confidentiality and integration of counselling within
mainstream care provision need to be addressed and potentially adapted. Implications for other non-Western countries with
little mental health resources are discussed.
The provision of mental health services over the Internet is becoming increasingly commonplace as new technologies continue to develop. Evidence in support of the efficacy of many such interventions is accumulating. Given the potential global reach of Internet-based psychological services, the authors examine ethical issues relating to this growing area of practice through the lens of the Universal Declaration of Ethical Principles for Psychologists (International Union of Psychological Science, 2008). They also raise issues relating to potential liability risks and offer recommendations intended to guide mental health practitioners who are considering involvement in the provision of Internet-based services.
Well-implemented informed consent procedures demonstrate psychotherapists' respect for clients' right to self-determination and can initiate meaningful contributions to treatment through enhancing mutual trust, building rapport, and facilitating a sense of ownership. This article details key components of informed consent to psychotherapy by placing them within real-world psychotherapy scenarios. We provide information on client-therapist discussions of the nature and course of therapy, fees and payment policies, the involvement of third parties, confidentiality policies, and new and untested treatments. In addition, this article addresses informed consent procedures for individuals with impaired cognitive capacities and under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations.
There are numerous unique legal and ethical concerns that clinicians should consider when counselling children, adolescents, and their families. These, however, are not generally emphasised in most ethics courses in graduate training programs. While ethical codes vary among professional organisations (e.g., marriage and family therapy, counselling, social work, psychology), this article addresses many subjects that are common across disciplines, such as (1) informed consent, (2) types of confidentiality, exceptions, and reporting issues, (3) sharing information revealed to the practitioner to parents, and (4) subpoenas. Other important topics are the importance of counsellor competencies, multicultural considerations, and special topics including the use of touch and the role of the professional in divorce situations. Additionally, the role of computing and social media can enhance relationships for children, or be sources of stress or trauma. Lastly, laws, which typically supersede ethical codes often vary from state to state and nation to nation, and it is imperative that clinicians are cognisant of those in their jurisdiction.
Confidentiality is important in healthcare practice, however, under certain circumstances, confidentiality is breached. In this paper, mental health professionals' (MHPs) practices related to informing imprisoned patients about confidentiality and its limits are presented.
Twenty-four MHPs working in Swiss prisons were interviewed. Data analysis involved qualitative thematic coding and was validated by discussing results with external experts and study participants.
For expert evaluations and court-ordered therapies, participants informed patients that information revealed during these consultations is not bound by confidentiality rules. The practice of routinely informing patients about confidentiality and its limits became more complex in voluntary therapies, for which participants described four approaches and provided justifications in favour of or against their use.
Further training and continued education are needed to improve physicians' ethical and legal knowledge about confidentiality disclosures. In order to promote ethical practices, it is important to understand and address existing motivations, attitudes and behaviours that impede appropriate patient information. Our study adds important new knowledge about the limits to confidentiality, particularly for providers working with vulnerable populations. Results from this study reflect typical ethical and practical dilemmas faced by and of interest to physicians working in forensic medicine and other related settings.
Copyright © 2015 Elsevier Ltd. All rights reserved.
The authors present the results of a survey of ethical complaints reported to state licensing boards, raise concerns about specific areas of ethical complaints and violations, and make suggestions regarding ameliorating problem areas.
The present study is a cross-sectional survey that investigates ethical practices among Chinese psychotherapists from the perspective of a large representative sample of Chinese clients (N = 1100). In reports from clients, we found that psychotherapists did poorly in providing informed consent, and had other ethical difficulties in the therapeutic setting and with dual relationships. We conclude that Chinese culture, especially Confucianism had significant impact on the attitudes towards the psychotherapists' ethical practices, which complicated ethical dilemmas. It is important for cross-cultural psychotherapists to become sensitive to the influences of traditional Chinese culture when counseling Chinese clients.
The aim of the research was to assess the views of young people about school counselling. In total, 415 pupils from five secondary schools took part in the survey. A smaller number of these pupils took part in focus groups (n=9) to explore their views in more depth. In general, the young people seemed to value having a school counsellor. Most were aware of the school counselling service, although a substantial number (21%) indicated a lack of awareness. For many who were aware, their knowledge of the service was limited. Just over one third of the pupils stated that they would go to see the school counsellor, and girls were more likely to state this than boys. The confidentiality of the service was perceived to be one of the benefits. However, this was also reported to be a hindering factor—the concern that it may not, in fact, be confidential. Two other main reasons for not accessing the service were the counsellor being a stranger and (for boys in particular) a concern about other people finding out (associated with the social stigma of going for counselling). Suggestions to improve the school counselling service included a room in a discrete location, better promotion of the service, more counsellors or a full-time counsellor, and ways to get to know the counsellor better. Those responsible for developing and managing school counselling services should consider these suggestions.
Cultural, personal, contextual, and universal factors integrate to form the personal cultural identities of both the counsellor and the client. These personal cultural identities may have a dramatic impact on the success of the counselling process and must be taken into account in both theory and practice. The culture-infused counselling model builds on the concept of personal cultural identity to form a conceptual framework for enhancing the multicultural competence of practitioners and for optimizing therapeutic outcomes with a wide range of clientele. The specific attitudes, knowledge, and skills required for multicultural competence are described, expanding upon and enhancing earlier theoretical conceptualizations of multicultural counselling competencies. This detailed elaboration of specific multicultural counselling competencies provides a foundation for counsellor education and continued professional development.
ABSTRACT Over the last century psychotherapy has developed alongside technology and legal test cases, with each impacting on the other. Client confidentiality is no longer simply a moral obligation on the part of the psychotherapist or a valuable psychotherapeutic tool. It is tied up in complex legislation and legal rights, duties and obligations as well as codes of ethics and conduct issued by each of the psychotherapy organizations.
Traditionally, there have been few legal actions brought against psychotherapists that allege negligent psychotherapy and negligent treatment of psychiatric disorders. However, in the case of Osheroff v. Chestnut Lodge, a patient-physician (Dr. Osheroff) sued Chestnut Lodge, a private psychiatric facility, for negligence based on the staff's decision to apply a psychodynamic model of treatment (through psychotherapy) and not a biological model. The case sparked a heated debate between adherents of the psychodynamic model and those of the biological model. This article explores the implications of the Osheroff litigation for mental health professionals. It is proposed that an interactive informed consent process be used to protect psychotherapists against Osheroff-type litigation.
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