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Ethics and Social Welfare
ISSN: 1749-6535 (Print) 1749-6543 (Online) Journal homepage: https://www.tandfonline.com/loi/resw20
Confidentiality and Ethical Practice in Child and
Adolescent Mental Health
Steven Walker
To cite this article: Steven Walker (2019): Confidentiality and Ethical Practice in Child and
Adolescent Mental Health, Ethics and Social Welfare, DOI: 10.1080/17496535.2019.1649444
To link to this article: https://doi.org/10.1080/17496535.2019.1649444
Published online: 04 Aug 2019.
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Confidentiality and Ethical Practice in Child and Adolescent
Mental Health
Steven Walker
School of Health and Social Care, University of Essex Faculty of Social Sciences, Health and Social Care,
Colchester, UK
ABSTRACT
This paper examines the concept of confidentiality and the quality
of the relationship between young people experiencing mental
health problems and social workers supporting them. The nature
of a therapeutic intervention brings into focus the rigidities and
complexities in adhering to agency and professional guidelines on
confidentiality. The paper highlights the tensions and ethical
dilemmas in making decisions about risk and whether, when, and
how to breach confidentiality.
KEYWORDS
Confidentiality; mental
health; young people;
therapeutic relationship;
dilemmas
Introduction
A coroner recently criticised Samaritans’confidentiality policy and accused it of showing a
complete lack of co-operation following a teenager’s death (Wales Online 2014). An
inquest following the suicide of a mother whose son had died three months previously
has ruled that the uncooperative attitude of Samaritans may have been a contributing
factor to her death. Dennis and Suzanne Williams discovered that their 18-year-old son
called the helpline charity before he drowned but, due to Samaritans’procedures on
privacy, were unable to learn more about these conversations from the charity. Samaritans
have strict confidentiality rules which it says are essential to the service it provides. The
Daily Post in Wales reported that coroner Dewi Pritchard Jones criticised the charity for
refusing to help with the enquiry into Matthew Williams’death, saying that the charity
only yielded after its chief executive was threatened with a summons to appear before
the coroner. Pritchard Jones told the inquiry in Llangefni: “The good thing to come out
of the episode with the Samaritans is that they realise that, when coroners ask for assist-
ance, it is to establish the circumstances of the death and not to ask why. ‘My hope and
indications from the Samaritans is there will be better co-operation in future.’”
The above example is a stark illustration of the ethical dilemmas faced by those staff
who find themselves in communication with a troubled young person who may be con-
templating suicide (Walker and Beckett 2011). It has two elements: the first is the level of
risk perceived or assessed by the Samaritans worker who took calls from the child, the
second is the degree of flexibility around disclosing confidential information from a
dead person which may have assisted the parents grieving process.
© 2019 Informa UK Limited, trading as Taylor & Francis Group
CONTACT Steven Walker swalk54@btinternet.com https://www.researchgate.net/profile/Steven_Walker23
University of Essex Faculty of Social Sciences, Health and Social Care, Wivenhoe Park, Colchester, CO4 3SQ, UK
ETHICS AND SOCIAL WELFARE
https://doi.org/10.1080/17496535.2019.1649444
UK Social Workers work under their agency policies on client confidentiality and their
professional association (BASW 2012) code of ethics:
Social workers should respect the principles of confidentiality that apply to their relationships
and ensure that confidential information is only divulged with the consent of the person using
social work services or the informant. Exceptions to this may only be justified on the basis of a
greater ethical requirement such as evidence of serious risk or the preservation of life. Social
workers need to explain the nature of that confidentiality to people with whom they work and
any circumstances where confidentiality must be waived should be made explicit. Social
workers should identify dilemmas about confidentiality and seek support to address these
issues.
The context of child and adolescent mental health
Young people communicate their thoughts and feelings in often disguised or oblique
ways. A young person may complain of a persistent headache or tummy ache and
after medical investigations find nothing abnormal. Skilled listening then enables that
young person to reveal anxiety about their body image, sexual abuse, bullying or par-
ental conflict (Department of Health/National Institute for Mental Health in England
2009). A young person in a painfully sensitive conversation with a social worker may
talk about ‘ending it all’or feeling they cannot go on, but without making an active
suicide plan. GP’s use a screening tool to assess risk in young people based on depth
and length of low mood and can flag up an urgent referral to Child and Adolescent
Mental Health Services (CAMHS), but not all young people go to GP’s or disclose the
true level of despair. Often the first sign of trouble is an overdose admission to A&E
or self-harm revealed during school PE lessons.
A young person with a developing eating disorder may confound medical practitioners
investigating any biological aetiology and conventionally-trained Psychiatrists, but a social
worker may, after convening a family assessment, conclude that the young person’s symp-
toms are part of a wider systemic pathology with origins in family dynamics, indirect com-
munication patterns and parental discord (NHS England 2014). It is no surprise that Family
Therapy is a front line treatment for childhood eating disorders (Walker 2012b).
Social workers and others working with troubled young people are going to face
increasing situations where these ethical dilemmas present themselves as CAMHS services
face cutbacks, long treatment waiting times, and increasing demand from a generation of
young people facing the stresses and pressures of today’s modern environment.
Increasing demand for help
Evidence of the level of mental health problems in young people has been emerging for
many years. The NSPCC reported that in 2018 the number of referrals by schools in
England seeking mental health treatment for pupils has risen by more than a third over
the last three years (The Guardian 2018). The Nuffield Trust published research in Septem-
ber 2018 analysing mental health and well-being trends among children and young
people over the past two decades (Pitchforth et al. 2018). They looked at data from
140,830 participants aged between 4 and 24 across 36 national surveys in England, Scot-
land and Wales. They found a striking, sixfold increase in how many children and young
2S. WALKER
people in England reported having a long-standing mental health condition between
1995 and 2014 (from 0.8 to 4.8 per cent). Among young adults between 16 and 24,
there was a tenfold increase from 0.6 per cent to just under 6 per cent.
Increasing numbers of teenagers in England and Wales are killing themselves according
to the UK Office for National Statistics (2017). The data shows that there were 177 suicides
among 15–19-year olds in 2017, compared with 110 in 2010 and more than in every year
since then except 2015, when the toll was 186. Fifty-six girls and women in the age group
killed themselves last year, the highest number since records began in 1981. The suicide
rate among that group, 3.5 per 100,000 people, was also the highest on record, and well up
on the rate of 2.1 per 100,000 in 2010. The suicide rate among boys and men that age
climbed to 7.1 per 100,000. There were 121 young male suicides in 2018 compared to
74 in 2010.
The number of girls under the age of 18 being treated in hospital in England after self-
harming has nearly doubled compared with 20 years ago, according to NHS figures
released in 2018 (Morgan et al. 2017). The figure reached 13,463 in 2018 against 7327 in
1997. The number of girls treated for attempting a substance overdose has risen more
than tenfold to 2736 last year from 249 in 1997, while the number of boys treated increased
over the past 21 years from 152 to 839 in 2017. The Care Quality Commission (CQC)
reported in late 2017 that child and adolescent mental health services (CAMHS) are over-
whelmed with demand, and young people are waiting up to 18 months to be treated
(Care Quality Commission 2018). The CQC warned that long delays for treatment are dama-
ging the health of young people with anxiety, depression and other conditions. In the same
year, the Children’s Commissioner (2018) expressed her concerns that only between a
quarter and a fifth of children with mental health conditions received help in 2018.
Children’s rights
The promotion of young people’s rights in the context of their mental health problems is as
important as it is complex and highlights important ethical questions. It is only 30 years ago
in 1989 that the United Nations (UN) General Assembly adopted a landmark –the Conven-
tion on the Rights of the Child (CRC) (Unicef 1989). The Convention recognised that children
are human beings and more than just passive objects of care and charity who are entitled to
the enjoyment of a distinct set of rights in accordance with their specific needs. The United
Kingdom ratified the Convention in 1991, with several declarations and reservations, and
made its first report to the Committee on the Rights of the Child in January 1995. Concerns
raised by the Committee about British children included the growth in child poverty and
inequality, the extent of violence towards children, the use of custody for young
offenders, the low age of criminal responsibility, and the lack of opportunities for children
and young people to express views (Children’s Rights Alliance for England 2012).
The 2002 report of the Committee expressed similar concerns, including the welfare of
children in custody, unequal treatment of asylum seekers, and the negative impact of
poverty on children’s rights. There has subsequently been an emphasis on developing
innovative methods of eliciting their views and enabling young people to identify their
own agenda as far as possible, rather than responding to an adult-imposed one. For
those staffengaged with a young person, this raises ethical dilemmas about respecting
ETHICS AND SOCIAL WELFARE 3
the child’s wishes, feelings and rights against agency policies, ethical codes of conduct and
the potential for disclosing confidential information in future court proceedings.
Focusing on the organisation and delivery of children’s services, as well as managing
the challenges in multi-disciplinary working and training runs the risk of neglecting
young people’s perceptions and experiences. The evidence of adult client/patient/
service user consultation, over changes in service provision in health and social care,
is limited (Walker 2012a). For children’s services in general, and child and adolescent
mental health services in particular, it is unusual. Children and young people’s perspec-
tives have rarely been explored in relation to the help they are offered towards their
mental health difficulties (Coram Voice 2017).
Professionals are expected to work hard to seize every opportunity to enable a troubled
young person to express their wishes and feelings about the kind of CAMHS support they
want. The Children Act 1989 makes it quite clear that their needs are paramount, but social
workers have always got an eye on the future and have to balance those needs with the
potential for establishing long term more secure and safe relationships. Empowering a
young person may undermine a parent, dent their confidence and set up a conflictual
dynamic which is hard to mitigate in future (Walker 2011).
Confidentiality
Children and young people require the help and advice of a wide variety of sources at
times of stress and unhappiness in their lives. They may want to talk in confidence
about worrying feelings or behaviour. The legal position in these circumstances is con-
fused, with agencies and professional groups such as counsellors or psychotherapists
relying on voluntary codes of practice guidance. A difficult dilemma frequently arises
for social workers when children are considering whether a helping service is acceptable
while the staffare required to disclose information to others in certain situations, for
example where child protection concerns are aroused.
The agency policies should be accessible to children and clearly state the limits to confi-
dentiality. But in doing so, many practitioners know they could be discouraging the
sharing of important feelings and information. Staffknow only too well the importance
of establishing trust and confidence in vulnerable young people and constantly have to
tread the line between facilitating sensitive communication and selecting what needs
to be passed on to parents, colleagues or to third parties. In a therapeutic context disclos-
ure of sexual or physical abuse could be an unnerving and risky thing for a vulnerable
young person.
But strict compliance with agency guidelines require immediate reporting to a line
manager and then potential child protection intervention with police involvement for a
criminal investigation. Legal protocols demand the suspension of any therapeutic work
in case it is challenged by defence lawyers who may try to suggest that the therapy
was putting ideas into the mind of the young person or inadvertently helping them elab-
orate if not make up an allegation. The evidence from the criminal law is that very few
sexual abuse cases ever get to court, and of those that do a tiny proportion conclude in
a successful prosecution often carrying a short prison sentence. Young people who may
have been put through a gruelling, humiliating, traumatic court procedure are left
feeling that justice has not been done, and they feel often re-abused. In addition due to
4S. WALKER
over-hasty and insensitive implementation of the confidentiality agreement, the young
person completely distrusts social workers.
The cessation of therapeutic work could destroy months of careful work, and prevent
the young person to continue any therapeutic work or in the future. Ideally, where disclos-
ure needs to be made against a young person’s wishes, it is good practice to inform the
young person in advance and give her or him the chance to disclose the information
first. But after a court appearance even shielded by video link, the child can emerge
having been accused of lying and end up feeling re-abused in public.
What does ethical practice look like in CAMHS?
Social workers in a variety of work contexts in statutory or voluntary agencies, organised
generically or in specialist teams, wherever they are likely to encounter children and young
people as clients or carers, are potentially going to need to develop awareness and skills in
child and adolescent mental health practice. In terms of the policy and organisational
context, workers need to follow these ethical principles when planning to intervene in
the lives of children and young people on the grounds of disturbed or disturbing
behaviour.
.Informing the child fully, consulting the child and taking her/his views and wishes into
consideration.
.Accepting that in the absence of any specific statutory limitation, children gain the right
to make decisions for themselves when they have ‘sufficient understanding and
intelligence’.
.Respecting , in particular, the child’s independent right to consent or withhold consent
to treatment as appropriate; and where a child is incapable of giving an informed
consent ensuring that the parents’consent is sought, save in emergencies.
.Ensuring that any intervention is the least restrictive alternative, and leads to the least
possible segregation from the child’s family, friends, community and ordinary school.
.Children without the support of family or friends in treatment decisions should have
access to independent visitors, advice and advocacy organisations. In the event of a
parent wishing to override the child’s refusal to be treated, a legal challenge may be
justified if there is evidence that the parent is not acting in the best interests of the
child.
Like all guidelines these need to be considered in the context of each individual young
person (Jones 2011). Understanding the ethical dilemmas around when and how to pass on
confidential information are critical. Simply following procedures could end up destroying a
young person’s faith in the helping professions, with a sexual abuser avoiding justice, a
family traumatised, and the young person re-victimised. If a young person discloses historic
abuse and is not in immediate risk, is it good practice to maintain confidentiality and con-
tinue working with them, or not, if you assess that the perpetrator may become a danger
again at some point and the young person under duress unable to disclose future abuse?
The concepts need to be embedded within inter-agency child and adolescent mental
health working. This ensures that professionals are working together to agree a shared
outcome for the child or young person and their family by having a common focus and
ETHICS AND SOCIAL WELFARE 5
by helping to support the child with the results they need for optimum psychological
development and wellbeing. Many inquiries have cited the lack of co-operation and com-
munication across professionals and agencies as the reason why children have been
harmed or killed by parents or carers.
CAMHS guidelines often concentrate on the management of a single mental disorder
instead of taking a holistic, systemic and co-ordinated approach to care and treatment of
the whole person and their wider context (Walker 2013). Too often young people complain
that specialist CAMH services focus on their symptoms or diagnostic label and ignore their
social needs (Marshall and Smith 2017). The ethical issues and dilemmas around confiden-
tiality are rarely explicitly understood or managed sensitively in the context of child sexual
abuse which may lie at the heart of a young person’s mental illness (Walker 2019). This
paper has illuminated an area of practice that will become more prevalent as mental
illness and its causes becomes a significant part of modern social work practice.
Disclosure statement
No potential conflict of interest was reported by the author.
Notes on contributor
Steven Walker,MPhil, is a Sessional Lecturer in the School of Health and Social Care, University of
Essex, a member of the Children and Young Persons Mental Health Coalition, and International
Family Therapy Association. He qualified as a social worker in 1985 at the London School of Econ-
omics and Political Science with an MSc in Social Work and Social Policy and was Head of Child
and Adolescent Mental Health at Anglia Ruskin University.
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