Ethics Rounds

Our previous "Ethics Rounds" posed the following clinical vignette:

I am a psychologist who works mainly with adolescents and young adults. This fall I began treating a 20-year-old woman who came to therapy because of difficulties she was experiencing in an intimate relationship. My patient disclosed that when she was 12, an uncle who had come to stay with the family for several weeks sexually molested her on a number of occasions. My patient reports that I am the first person she has told that her uncle "messed with" her and that were anyone in the family to learn what happened a major and perhaps irreparable rift would inevitably result. The uncle has since moved to a distant part of the state and for the last several years my patient has been able to make plans to be away when he visits.

As discussed in the May "Ethics Rounds," child-abuse reporting laws do not always address how far into the past their mandates extend. The vignette occurred in a state where the law was silent concerning this question. The psychologist sought an official opinion and was informed that no report was legally mandated. The psychologist was also informed that the law provided the discretion to report. The psychologist wondered whether, even in the absence of a legal requirement, there might be an ethical obligation to break confidentiality and tell some authority about the uncle's behavior.

"Ethics Rounds" sought the advice of ethics experts to answer this question: Gerry Koocher, PhD, Mary Brabeck, PhD, and Kalina Brabeck. Gerry Koocher, professor and dean of the School for Health Studies at Simmons College, is co-author (with Patricia Keith-Spiegel, PhD) of "Ethics in Psychology: Professional Standards and Cases" (Oxford University Press, 1998); Mary Brabeck, PhD, professor and dean, counseling, developmental and educational psychology, Boston College, is editor of "Practicing Feminist Ethics in Psychology" (APA, 2000); and Kalina Brabeck is a doctoral student in the counseling psychology program at the University of Texas, Austin.

Gerry Koocher's advice

In planning a response to this scenario, a psychologist should first take stock of the facts and the duties owed the client. Based on the case as presented, we know what the client has told the therapist and we know that the potential reporting obligations depend on state law. But wait; what state's law? Suppose the abuse occurred in Minnesota, the alleged perpetrator lives in Washington and the client disclosed her saga to the therapist in Massachusetts? Let us assume that the therapy takes place in vivo, as opposed to occurring across state lines by electronic means.

Fundamental ethical principles such as fidelity (i.e., trustworthiness), beneficence (i.e., doing good) and nonmaleficence (i.e., doing no harm) now become critically important guideposts. What does the client want and need from the therapist? Most likely, the client wants to process the long-concealed distress and address myriad emotions, including anger, shame, sadness, guilt and a host of other issues commonly experienced by victims of sexual abuse. The client wants and needs to do this in a supportive, safe and reassuring context in order to regain a sense of control and mastery over the frightening events of the past that radiate into her present. Based on experience, the therapist may anticipate these needs, but must be guided by the client's goals, wishes and pace. The therapist must listen carefully, offer encouragement, and ask the client about her needs and goals.

The therapist need not investigate or authenticate the client's allegations, but simply work to assist within her own reality. An ethical challenge will appear if the client expresses a wish to confront, or seek a legal remedy from, the alleged perpetrator. In such instances, the therapist may encounter requests to participate as an advocate for the client. Although a therapist can document the client's distress, offer diagnostic opinions, discuss future treatment needs and provide support, caution dictates that the therapist avoid requests to validate the occurrence of abuse or participate as an advocate for the client in court or "therapeutic" confrontations with the alleged perpetrator. The ethical obligations here include maintaining the client's confidence and attempting to help improve her mental health. One should not risk potential harm to the client by abandoning the role of therapist for the potentially incongruent role of advocate. In addition, a psychologist should never participate in defaming or otherwise causing harm to an alleged perpetrator without a sound evaluative basis for doing so.

If the client expresses fear for the safety of other potential victims, the psychologist can help the client evaluate her options. Taking steps to confront an alleged perpetrator by reporting to state authorities or notifying others will require disclosure of the client's status as a prior victim. Such actions may result in unwanted notoriety, criticism from family members and increased personal discomfort. Some clients may be willing to take such steps while others may not be. The choice belongs to the client.

In the final analysis, the psychologist must respect the client's wishes or risk committing yet another betrayal potentially more devastating than the prior abuse. The psychologist should focus attention on the needs and well being of the client, maintain her trust, strive to assist in her recovery and avoid further harm to her.

The Brabecks' advice

Three levels of ethical concerns should inform psychologists' decision-making: the aspirational level (ideal, moral principles), the professional level (standards set by a professional organization, e.g., APA) and the legal level (laws that mandate the standards of behavior that society will tolerate). When a conflict exists (e.g., the aspirational obligation to respect client's autonomy and the legal obligation to report abuse), psychologists face ethical dilemmas. Confidentiality is the bedrock of psychotherapy. If a psychologist breaks confidentiality, he or she violates the obligation to respect the client (the principles of justice and autonomy) and may cause harm (violating the principle of nonmaleficence). At the professional level, psychologists "have a primary obligation" to respect the confidentiality rights (Standard 5.01). At the legal level, privacy is a right guaranteed by the Fourth, Fifth and Fifteenth amendments of the U.S. Constitution and states have laws that mandate confidentiality.

There are, however, limits to confidentiality. The principles of nonmaleficence (avoid harm) and beneficence (ensure people's well-being) require that psychologists break confidentiality when a client's actions pose potential harm to self or others. At the professional level, "Psychologists disclose confidential information without the protect the patient or client or others from harm" (Standard 5.05 [a]). Moreover, psychologists must know state mandated limits and inform their clients of the exceptions to confidentiality (Standard 5.02).

If the law neither mandates nor prohibits reporting in a specified time interval, the psychologist must evaluate competing obligations. A psychologist's first duty is to ensure that his or her client is not harmed. In this case, the client is not a minor and not in imminent danger of sexual abuse.

Reporting abuse without consent may communicate a lack of respect for the client and risks harming the therapeutic relationship, which is necessary for the client to safely explore the serious issues she raised. Breaking confidentiality may rob the client of the opportunity to gain insight into the reasons for her silence, to name the wrong done to her and to confront others with the truth, thereby gaining control over her life. Furthermore, the client may conclude that no one is trustworthy and continue her silence regarding the abuse. If trust is broken, the psychologist violates the principle of fidelity and the client may end therapy prematurely. Psychologists have a professional mandate to "not abandon their clients" (Standard 4.08[a]).

Finally, if the psychologist has reason to believe that the client's family will abandon her or will retaliate against her, the psychologist's disclosure might put the client at risk.

To protect others from harm, the psychologist should explore whether the client is aware of any ongoing abuse, or danger of abuse. If the client lacks the answers to these questions, the potential harm from these relatively unknown risks must be weighed against the risks to the client if confidentiality is broken.

On the other hand, by not reporting the abuse, the psychologist may collude with the client in keeping her silence and in letting the abuser maintain power and control over her, which violates her autonomy and may not be in her best welfare. The psychologist's failure to disclose the abuse may make him or her a part of the greater system that fosters silence and fails to condemn abuse of the powerless, which may abet injustice and does not show care for society. If the client perceives the psychologist as a person of authority, his or her participation in this system of silence may exacerbate the client's sense of powerlessness and hopelessness.

The best option is for the psychologist to maintain confidentiality and use the therapeutic relationship as a vehicle to empower the client to report the abuse to appropriate authorities. If this is not an option for her at this time, the psychologist might consider making disclosure a goal of therapy. If other family members have also been abused, breaking the silence may enable others to do the same or prevent additional abuse. Such a resolution might enhance the client's sense of autonomy, maintain the trust of the therapeutic alliance, end the self-silencing that the abuse fostered and restore the power of the client's voice.