40. 保密及其他伦理问题
本章知识点阐述
40 Confidentiality and other ethical issues The first part of this chapter will be devoted exclusively to confidentiality, because it is one of the most important ethical issues for a counsellor. Other aspects of professional ethics will be considered in the second part of the chapter. CONFIDENTIALITY For counselling to be maximally effective, the person seeking help must feel secure in the knowledge that what they tell the counsellor is to be treated with a high degree of confidentiality. In an ideal world they would be offered total confidentiality so that they would feel free to openly explore with the counsellor the darkest recesses of their mind, and to discuss the most intimate details of their thoughts. As new counsellors we naively believed that we could at all times give those who sought our help an assurance that what was said in a counselling session was between them and us and would not be discussed with others. We very soon learnt that this was an idealistic belief and found that in practice it is generally not possible, advisable or ethical to offer total confidentiality. As a counsellor you may at times be troubled by some personal difficulties regarding confidentiality and may need to talk with your supervisor about these. Counsellors are faced with a dilemma with regard to confidentiality. Unless we give a person who seeks our help an assurance that what they tell us will be in confidence, they are unlikely to be open with us. However, there are limits to the level of confidentiality that we can offer, and we need to be clear with the people who seek our help about these limits. Most importantly, as counsellors we need to be aware of the limits to the confidentiality that we are offering.
Absolute confidentiality is often not possible
Many experienced counsellors would agree that promising total confidentiality is unethical (Shillito-Clarke, 2009). It is certainly true that confidentiality is compromised by the following: • the need to keep records • the requirements of the counsellor’s own supervision • the need to protect others • working in conjunction with other professionals • participation in educational training programs, conferences, workshops and seminars • cases where the law requires disclosure of information. the above list will now be discussed in detail.
THE NEED TO KEEP RECORDS As explained in Chapter 38, there are compelling reasons for keeping good records. Counsellors who work in agencies frequently use computerised systems or centralised filing systems for such records. This may make it possible for other counsellors and non-counselling staff such as receptionists and filing clerks to have access to confidential records. Some counsellors omit to note certain categories of sensitive material on their record cards as a way of protecting those who seek counselling help. However» there are obvious consequences if this policy is adopted, as important information may be overlooked or forgotten during subsequent counselling sessions. Clearly, for the protection of those who seek help, computerised records need to be protected by adequate security systems. Similarly, hard-copy records should not be left lying around in places where they can be read by unauthorised people, and should be stored in lockable filing cabinets or in a secure filing room.
REQUIREMENTS OF THE COUNSELLOR'S OWN SUPERVISION 1 he requirements of professional supervision, as described in Chapter 41, demand that counsellors be free to fully disclose to their supervisors material relating to people who are seeking help. This is essential if the best possible service is to be provided, and is also necessary for the wellbeing of counsellors themselves. Some counsellors openly talk with the people who seek their help about the requirements of professional supervision and sometimes it can be reassuring for a person to know that their counsellor is receiving supervision.
Counsellor supervision is in the best interests of the people who seek help
THE NEED TO PROTECT OTHERS Experienced counsellors sometimes work with people who are contemplating suicide, with people who can be dangerous, and with those who have committed serious offences against other people and may possibly repeat such behaviour. Counsellors have responsibilities to those who seek help and also to the community’. Consequently, there may be instances where a counsellor needs to divulge information to protect the person who is seeking help from self-harm, or to protect a third party. For example, if a counsellor knows that the person who is seeking their help possesses a gun and intends to kill someone, then it would be unethical and irresponsible if the person at risk, the police and the psychiatric authorities were not informed. Consultation with a supervisor or experienced practitioner is strongly recommended, whenever this would not cause undue delay. The aim should be to ensure that the person seeking help receives a high level of care that is as respectful of their capacity for self-determination as circumstances permit, while also ensuring the safety of others who may be at risk.
WORKING IN CONJUNCTION WITH OTHER PROFESSIONALS Professionals such as psychiatrists, medical practitioners, psychologists, social workers, clergy and welfare workers frequently phone counsellors to talk with them about people who are seeking their help, and also seeking the counsellor’s help. It is sometimes in the interests of such people for other professionals to be appropriately informed about their situations. It is also desirable for counsellors to maintain good working relationships with other helping professionals. Sensible judgements need to be made about what information can be, and is, disclosed, and what is withheld. It is important to try to avoid compromising a person’s trust in you as a counsellor and to respect their lights as a person.
It may be advantageous for the person seeking help if the counsellor works in collaboration with other professionals
If as a counsellor you believe that it is desirable that sensitive material relating to a person seeking help be disclosed to another professional, then, unless there are unusual and compelling reasons for not doing so, the permission of the person concerned should be obtained. Obtaining their permission involves informing them about what you wish to do and why. They are then able to give informed consent. Preferably, this informed consent should be verified in writing so there can be no misunderstanding. Many agencies have a standard consent form which can be used when information is to be shared. 1 he general practice is for this form to be discussed with the person concerned and then signed by both the person and the counsellor. Where two or more members of a family require counselling help, family therapy may be useful. However, if family therapy is not possible, or is considered inappropriate, then the helping professionals involved with individual members of the family are likely to achieve more successful outcomes if they consult with each other, have case conferences and work together as a team. If such cooperation and teamwork is to occur, the process needs to be made transparent to all family members involved, and their consent for the sharing of information needs to be obtained. Sometimes you may discover that a person who is seeking counselling help from you is also consulting another counsellor. There is rarely justification for two counsellors to work with the same person, so after discussion with the person it is sensible to contact the other counsellor to decide who will take over the case. However, as with most situations, there can be exceptions. In a small number of cases, if good contact is maintained between two counsellors, it may be possible for them to both remain involved provided that they agree in setting clear boundaries and goals for the work that each of them will undertake.
EDUCATIONAL TRAINING PROGRAMS, CONFERENCES, WORKSHOPS AND SEMINARS Another problem area regarding confidentiality concerns ongoing training, upgrading of skills and sharing of new techniques. Counsellors need to grow and develop as people and as counsellors. This can partly be done through personal supervision and partly through large group sharing at conferences, seminars, workshops and case conferences. Material presented at such events to people who sought or are seeking help can sometimes be disguised by changing names and other details, but often this is not possible, particularly when DVD recordings of counselling sessions are used. However, we should stress that it would be unethical to use material in this way without the prior written consent of the people involved who sought or are seeking help. Moreover, there could be legal as well as ethical problems if consent is not obtained. WHERE THE LAW REQUIRES DISCLOSURE OF INFORMATION Confidentiality may be limited by legal intervention. Sometimes counsellors are subpoenaed to give evidence in court and in such cases withholding information may be in contempt of court. Additionally, mandatory reporting is required by counsellors from certain professions in some countries or states with regard to issues such as child abuse.
RESPECTING A PERSON'S RIGHT TO PRIVACY Clearly, from the preceding discussion, there are many reasons why confidentiality in the counselling situation is limited. However, it is the counsellor’s task to ensure that confidentiality is preserved as far as is sensibly, legally and ethically possible. Assure the people who seek your help that you will do this to the best of your ability, because they need to feel that whatever they share with you is protected information, which will not be carelessly or unnecessarily divulged to others. It is quite unethical to talk about a person who is seeking help, or material related to them, to any person whatsoever, except in the circumstances previously described in this chapter. What a person shares with you is personal property and must not be shared around, so if you do have a need to talk about a person seeking help or their issues, talk with your supervisor.
We all like to have our privacy respected
You will need to make your own decisions, m consultation with your supervisor, about how best to deal with the confidentiality issue. Our policy is to be up-front with the people who seek our help and to explain the limits of confidentiality as they apply. For example, when we worked for an agency that had a particular confidentiality policy, we were careful to inform the people seeking help of the policy from that agency. As private practitioners, if we believe that it would be useful or sensible to divulge information for an ethically acceptable and professional reason, then we obtain the informed consent of the person involved. PROFESSIONAL ETHICS T he issue of confidentiality has been discussed in some detail. However, there are many other ethical issues for counsellors, and a new counsellor needs to be informed of these. Many counsellors belong to professional associations with codes of ethical conduct. These codes are readily available on request, and it is sensible for a new counsellor to read through the relevant code for the relevant profession. Some important ethical issues are included in the list below, and these will be discussed in subsequent paragraphs: • respect for the person seeking help • limits of the person-to-person counselling relationship • responsibility of the counsellor • counsellor competence • referral • termination of counselling • legal obligations • self-promotion. RESPECT FOR THE PERSON SEEKING HELP Regardless of who the person seeking help is, and regardless of their behaviour, they have come to you for help and deserve to be treated as a human being of worth. If you treasure them, through feeling valued they will be given the optimum conditions in which to maximise their potential as an individual. Most helping professionals agree that within each of us is the potential for good, and for that potential to be realised we need to feel OK about ourselves. Counsellors therefore have a responsibility to facilitate the process that enables those who seek their help to feel OK about themselves, and to increase their feelings of self-worth. If we try to impose our own moral values on the people who seek our help, we are likely to make them feel judged and to damage their self-worth. Moreover, they are likely to reject us as counsellors and to reject our values too. Paradoxically, if we are able to accept them, with whatever values they have, we are likely to find that as time passes they will move closer to us in their beliefs. This is inevitable because, as counsellors, we are, whether we like it or not, models for the people who seek our help. We have a responsibility to be good models. In this regard, it can be useful to create opportunities for those who seek our help to give us feedback about their experience of the counselling process. By doing this we can demonstrate respect for their views and their right to have some influence in the c ou nselling relatio nsh i p. We need to remember that the interests of the person seeking help must take precedence over the counsellor s during the counselling process. It is not ethical to use counselling sessions with people who seek help to work through our own issues. The correct time tor working through our issues is in supervision sessions. LIMITS OF THE COUNSELLING RELATIONSHIP In all our relationships we set limits. Each of us has a boundary around us to preserve our identity as an individual. The strength of that Boundary, and its nature, depends on who the relationship is with, and on the context of the relationship. The person- to-person counselling relationship is a special type of relationship, established by the person seeking help for a particular purpose. I hey enter into the relationship entrusting the counsellor with their wellbeing and expecting that the counsellor will, throughout the relationship, provide them with a safe environment in which they can work on the issues that trouble them.
As discussed previously, the person-to-person counselling relationship is not an equal relationship and, inevitably, whether the counsellor wishes it or not, they are in a position of power and influence. Counsellors often work with people who are in highly emotional states and are consequently very vulnerable. I he way that a counsellor relates to a person seeking help is not characteristic of human behaviour generally. A counsellor devotes most of their energy to listening to and understanding the person, so the person sees only a part of the counsellor’s character. In these circumstances, they may perceive a counsellor as unrealistically caring and giving. I he counsellor’s power and the person’s biased perception combine to make the person very vulnerable to offers of friendship or closeness.
I he counsellor is also vulnerable. In the counselling relationship, the person seeking help often shares innermost secrets, and so inevitably there may develop a real closeness between the person and the counsellor. Counsellors learn to be empathic, and so they develop special relationships with the people they seek to help. If they are not careful they too become vulnerable to offers of closer relationships than are appropriate. Counsellors therefore need to be careful not to discount signs that the counselling relationship is being compromised.
Counsellors can be vulnerable too!
Unfortunately, it is almost always unhelpful and damaging to the person seeking help when the counselling relationship is allowed to extend beyond the limits of the counselling situation. If such an extension occurs, the counsellor’s ability to attend to the person’s needs is seriously diminished, and there may well be serious psychological consequences for them. As a counsellor, it may at times be hard to refuse invitations to resist forming a closer relationship with a person seeking help than the counselling situation allows. However, it is important to remember that if we do not set appropriate boundaries we will be satisfying our own needs at the expense of the person seeking help. We will have abused our special position of trust as a professional, and we will have to live with that knowledge, and with any more serious consequences. Unfortunately, when counsellors breach appropriate boundaries they may damage or diminish the usefulness of the counselling process and reduce the possibility that the person seeking help will in the future seek further counselling help. Be aware of the danger signals if you notice that your relationship with a person seeking help is becoming too close, and bring the issue into the open by discussing it with your supervisor and with the person, if that is appropriate. Counsellors need to exercise care if they physically touch a person seeking help in any way. Unwelcome touching is not only unethical but may also be construed as sexual harassment.
RESPONSIBILITY OF THE COUNSELLOR Counsellors frequently experience a sense of conflict between their responsibilities to the person seeking help, to the agency that employs them and to the community. You will at times need to make your own decisions about which of these responsibilities needs to take precedence, and in our view the decision is unlikely to always be the same. If you are in doubt about any particular decision, consult your supervisor. Clearly, the counsellor has a responsibility to the person seeking help and needs to directly address their request for counselling help. When a person conies to you for confidential help, you have an obligation to give them that, or alternatively to be clear with them about why you are not able to do that. You cannot ethically fulfil their needs if providing a person with confidential help would: involve working in opposition to the policies of the organisation that employs you involve a breach of the law put other members of the community at risk be impossible for you personally. However, in these situations you need to be clear with the person seeking help about the situation, so that they understand the conditions under which they are talking to you.
Counsellors have a responsibility to the person seeking help, their employer, the community and themselves
Counsellors who are employed by an organisation or institution have a responsibility to that employing body. All the work they do within that organisation or institution needs to fulfil the requirements of the employing body, and to fit in with the philosophical expectations of the employing body. For example, when we (Kathryn and David) worked for the Child and Youth Mental Health Service in Queensland, it was our responsibility to comply with the policies of the Queensland Department of Health. If we had not been able to do that, then we would have had an ethical responsibility to discuss the issue with our employer, or to resign. Counsellors have to be aware at all times of their responsibilities to the community at large. As discussed earlier, this raises problems with regard to confidentiality7. Whenever a member of the community is at risk, property’ is likely to be damaged or other illegal actions are likely to occur or have occurred, then a counsellor needs to make a decision regarding what action is needed. Often such decisions do not involve choosing between black and white, but rather between shades of grey, and sometimes counsellors find it difficult to decide what is most appropriate in order to serve the needs of the person seeking help and the community in the long term. At these times the sensible approach is for the counsellor to talk through the ethical issues with their supervisor. COUNSELLOR COMPETENCE A counsellor has a responsibility7 to ensure that they give the highest possible standard of service. This cannot be done without adequate training and supervision. All counsellors need to attend to their own professional development and to have supervision from another counsellor on a regular basis. Failure to do this is certain to result in the counsellor’s own issues intruding into the counselling process, and this will be to the detriment of the people who seek their help (see Chapter 41). A counsellor also needs to be aware of the limits of their competence. We all have limits professionally and personally, and it is essential that as counsellors we are able to recognise our limits and to be open with people who seek our help about those limits. They have a right to know whether they are seeing someone who has, or does not have, the necessary abilities to give them the help they require. REFERRAL When a person’s needs cannot be adequately met by a counsellor, that counsellor has a responsibility to make an appropriate referral, in consultation with the person, to another suitable professional. However, it is not appropriate for a counsellor to avoid all difficult and unenjoyable work by excessively referring people to others. There is a responsibility on all counsellors to carry a fair load, and to be sensible about referral decisions. Such decisions are best made in consultation with a counsellor’s supervisor. Instead of referring to a more qualified and experienced counsellor, it may sometimes be appropriate for a counsellor to continue seeing a person seeking help while undergoing intensive supervision. If this happens, the counsellor has a responsibility7 to inform the person and seek their approval. Often referral is useful where people have special needs. For example, people with particular disabilities, people from other cultures and people who speak another language may benefit from referral to an agency (or professional) that can provide for their specific needs. When referring a person to another professional, it may be useful to contact the professional to whom the referral is being made, with the person’s permission, to ensure that the referral is acceptable and appropriate. TERMINATION OF COUNSELLING Termination of counselling needs to be carried out sensitively and with appropriate timing (see Chapter 12). It is not ethical to terminate counselling at a point where the person seeking help still needs further help. If for some unavoidable reason (such as leaving the district) you need to do this, then it is incumbent upon you to make a suitable referral to another counsellor who can continue to give the necessary7 support. LEGAL OBLIGATIONS Counsellors, like all other professionals and every7 other member of the community, need to operate within the law\ Therefore, as a counsellor, you need to familiarise yourself with the relevant legal requirements for your profession. It is particularly important to know whether reporting of specific behaviours (for example, suspected child abuse) is mandatory.
SELF-PROMOTION Most professional associations for counsellors have specific rules about advertising. 1 here is clearly an ethical issue with regard to the way in which counsellors describe themselves and their services. It is unethical for a counsellor to make claims about themselves or their services that are inaccurate or cannot be substantiated. Counsellors who do this not only put the people who seek help at risk, but may also face the possibility of prosecution.
Learning summary For counselling to be most effective, a high degree of confidentiality is required. Confidentiality is limited by: the need to keep records; professional supervision; the law; the protection of others; participation in training conferences; and cooperation with other professionals. Professional ethics relate to issues such as: respect for the person seeking help; limits to the relationship with them; responsibility to them; the employing agency and the community, competence, referral to others, termination of counselling; legal obligations; and self-promotion. References and further reading Bond, T. 2015, Standards and Ethics for Counselling in Action, 4th edn, SAGE, London. Corey, G., Corey, M.S., Corey, C. & Callanan, P. 2015, Issues and Ethics in the Helping Professions, 9th cdn, Cengage Learning, Stamford, CT. Shillito-Clarke, C. 2009, ‘Ethical issues in counselling psychology’, m K. Woolfc, S. Strawbridge, B. Doughs &’ W. Dryden (rds), Handbook of Counseling Psychology, 3rd cdn, SAGE, London,