Private Practice in Canada
Limits of Confidentiality
In order to ensure the privacy and dignity of our clients, confidentiality is an important component of services at Becker’s Psychological Services (BPS). All individuals receiving services from BPS will be assured of the protection of confidentiality, which includes the handling of files that contain case notes, records and psychological test results, unless otherwise required by law (Schulz, Sheppard, Lehr & Shepard, 2006). According to section B2 of the Canadian Counselling and Psychotherapy Association (2007) Code of Ethics, discussions between you and your counsellor are kept in strict confidence however, exceptions to confidentiality exist. The following situations are exceptions where counsellors must disclose confidential information:
1. When counsellor believes disclosure is necessary to prevent immediate and
critical harm to the client or another individual (CCPA, 2007).
2. When counsellors suspect abuse or neglect of a child (CCPA, 2007).
3. When a judge requires a counsellor to testify in court or to release the contents of
a file (CCPA, 2007).
4. When a client voluntarily requests disclosure and written consent is obtained
(CCA, 2001). If there is a need to disclose client information with another
professional or third party, the client will be consulted first and asked to sign a
release of information document.
5. When participating in multiple-client services, (i.e. group, marital or family
Therapy), the counsellor cannot guarantee other participants will not breach
confidentiality (CCA, 2001). Any participants involved in the counselling services
or marital, family or group counselling may seek access to the records of couples,
group or family sessions (CCA, 2001).
6. When a client files a complaint or claims professional liability
by the counsellor in a lawsuit (CCA, 2001).
According to Canadian Counselling and Psychotherapy Association (2007) Code of Ethics section B6, counsellors must keep records of each client in sufficient detail to track the sequence and nature of services rendered consistent with any legal, agency, regulatory or institutional requirements. The basic minimum information that is required includes legal name, address, phone number, referring agency and emergency contact information (CCA, 2001). All professional contact information is also required including duration of contact, date, length and name(s) of all present (CCA, 2001). All correspondence, reports and third party information requires documentation along with informed consent forms (CCA, 2001). Any consultations related to the client must be documented including phone calls and emails (CCA, 2001). Fees charged to the client must also be included (CCA, 2001).
In addition to basic information, psychological information is also required in documentation (CCA, 2001). Counselling information to keep track of progress and issues must be documented every session (CCA, 2001). Counselling information must be in an objective and factual manner and personal impressions, observations, hypotheses and observable behaviors must be identified (CCA, 2001). The purpose of recording information is to enhance counselling rather to ‘gather evidence’ in sufficient method to support continuity of counselling service (CCA, 2001). All records will be secured when creating, maintaining, storing, transferring and disposing in a method that is consistent with confidentiality (CCPA, 2007).
Normally, clients have a right of full access to their counselling records but the counsellor has the responsibility to ensure any access of counselling files if managed in an orderly and timely manner (CCA, 2001). Parents or legal guardians have a right to access their child’s counselling record upon formal request although this is not an absolute right (CCA, 2001). Overall, “Parents and guardians do not have an absolute right to know…rather should be evaluated on a ‘need to know’ basic (CCA, 2001).
Youth and Consent
Youth under the legal age who reside with their parents/guardians may receive counselling services from BPS however; youth are urged to acquire the consent of the parents, unless this consent is deemed harmful for the youth. Parents and guardians of younger children have the legal authority to consent on behalf of their child but as a child grows, the parents’ right to know will diminish or even terminate when the child achieves sufficient understanding and the ability to give informed consent (CCA, 2001).
Provincial regulations vary across Canada but in Alberta, the mature minor doctrine identifies a mature minor as a child/youth with sufficient intelligence and comprehension of the treatment proposed to understand the nature and inherent consequences of the proposed intervention even though a distinct age of maturation is not identified (College of Alberta Psychologists, 2007). The College of Alberta Psychologists (2007) recommends psychologists to “…err on the side of caution and uphold the duty of confidentiality owed to the mature minor, even where the guardian is the one seeking the information.” At BPS, the psychologists will ask the mature minor if they consent to disclosing of information to a guardian and make record of the consent or refusal of consent which should be retained on file.
According to section A2 of the CCPA (2007) Code of Ethics, it is the counsellor’s responsibility to participate in practices that are respectful of the civic, legal and moral rights of others. Counsellors must safeguard the rights and dignity of their clients (CCPA, 2007). Clients potentially come from a diverse background and according to section A10 of the CCPA (2007) Code of Ethics, counsellors must strive to respect and understand the diversity of their clients, which includes age differences, culture, ethnicity, gender, religion, sexual religion and socioeconomic status. Furthermore, the CCPA (2007) Code of Ethics requires counsellors to attempt to comprehend the diverse cultural backgrounds of their clients and communities while abstaining from condoning or participating in discriminatory practices based upon ethnicity, gender, religion, sexual orientation, age, economic status, colour, gender or marital status. Section D10 of the CCPA (2007) Code of Ethics also requires counsellors to proceed with caution when interpreting and judging the performance of minority group members and other groups who were not part of the population involved in standardization.
Ultimately, I believe a multicultural competent counsellor is culturally sensitive, understanding and knowledgeable about different cultures and groups, culturally aware, culturally responsive and possesses the skills and flexibility to work with clients who have culturally diverse (Schulz, Sheppard, Lehr & Sheppard, 2006). The multicultural competent counsellor is also aware of cultural biases or assumptions of society and the counsellor (Schulz et al., 2006). Furthermore, a counsellor with multicultural competencies follows the ethical guidelines established by CCPA and the CCA.
Schulz, Sheppard, Lehr and Sheppard (2006) strongly suggest that counsellor education, supervision and continuing professional development is integrated with attitudes, knowledge, awareness and skills essential to the competent and ethical provision of counselling in a diverse society. The CCA (2001) Standards of Practice urges counsellors to develop their understanding of diversity within the pluralistic society of Canada and such understandings should be part of counsellor education programs and continuation education experiences. Therapeutic and professional benefits such as viewing behavior in a cultural context, understanding of group inclusion, understanding diversity and adaptive functioning are also advantageous when the counselling profession embraces culture-infused practices (Schulz et al., 2006).
Breaching Confidence of HIV Positive Client with Risky Behaviors
Recently, a client named Mike disclosed his intentions of having unprotected sex with an identified other despite being HIV positive. If Mike reveals he has not told the other individual of his HIV status and will not inform the individual prior to sexual activity, I feel confidentiality must be breached in this situation for various ethical and legal reasons. The Canadian Counselling and Psychotherapy Association (2007) Code of Ethics states exceptions to confidentiality are applicable to this situation since “disclosure is required to prevent clear and imminent danger to the client or others.” I would act immediately without consulting with colleagues to reduce the likelihood of Mike from spreading HIV to another individual.
Through the process of informed consent, Mike was aware of the limits of confidentiality. My initial action would be to remind Mike of the risks associated with having unprotected sex and urge him to use protection and to inform the other individual that he has HIV. Precise documentation of the conversation is critical and obtaining as much information as possible concerning the other individual involved is important. If Mike persists on having uninformed and unprotected sex, I would remind him of the limits of confidentiality since he is putting another individual at risk.
Another ethical principle that relates to this case is the duty to warn which involves the counsellor detecting their client has intent or the potential to place others in imminent danger (CCA, 2001). Counsellors are to use the “lease intrusive steps to prevent harm” once they have reasonable grounds to believe imminent danger exists (CCA, 2001). In addition, confidentiality may be breached due to the duty to warn if clients with HIV positive are engaging in behavior that puts others at risk (CCA, 2001). According to section B3 in the CCPA (2007) Code of Ethics, the counsellor must employ reasonable care to warn the threatened individual to avert foreseeable dangers. Counsellors are to use the “lease intrusive steps to prevent harm” once they have reasonable grounds to believe imminent danger exists (CCA, 2001).
The Standards of Practice for Counsellors (CCA, 2001) specifically mentions confidentiality may be breached due to the duty to warn if clients with HIV positive are engaging in behavior that puts others at risk (CCA, 2001). I would phone or preferably visit the individual at risk to warn them about the foreseeable dangers and inform the individual Mike is HIV positive and discuss his potential intentions. It would also be important to discuss the high potential of transmitting HIV through unprotected sex and the consequences of HIV if the individual is not knowledgeable of HIV/AIDS. After further reviewing confidentiality, I would attempt to maintain my therapeutic relationship with Mike by saying “I hope you wish to continue working together and I am here to support you if you need me. However, if you prefer working with a different therapist, I would be happy help you find one.”
Although the primary issue is to warn the individual in order to prevent a foreseeable harm, previous legal situations also influenced my decision. According to Schulz, Sheppard, Lehr and Shepard (2006), the case of Tarasoff v. Regents of the University of California, a client informed his therapists that he intends to kill his girlfriend. Although the therapist contacted the police to inform them of the threat, the police decided he was rational and simply told him to avoid his girlfriend (Schulz et al., 2006). The client, killed Tarasoff and the Supreme Court of California imposed an affirmative duty on the therapist since he did not personally contact the potential victim (Schulz et al., 2006). The outcome of this case influenced therapist reporting requirements since therapists can now be held accountable for failing to warn potential victims of harm (Schulz et al., 2006). If I would uphold confidentiality and not do everything I can to warn the potential victim, including a personal warning, I could potentially be liable for harm to the victim.
Unfortunately, individuals with HIV face significant adversity due to stigmatization, discrimination and alienation therefore; confidentiality is a critical component of establishing a strong therapeutic relationship. The consequence of breaking confidentiality involves potentially ruining the therapeutic relationship between Mike and me after revealing to Mike that confidentiality will be breached. Furthermore, the experience of confidentiality limits may deter Mike from receiving counselling services in the future. After weighing the benefits and consequences to all potential courses of action, breaching confidentiality and warning the potential victim is the best alternative that concurs with ethical and legal guidelines.
Relationships With Clients
In the case of a 40-year old therapist decides to terminate therapy and establish a romantic relationship with a client who reciprocates attraction; I believe the therapist is behaving unethically. According to section B11 in the CCPA (2007) Code of Ethics, counsellors remain accountable for all relationships with former clients and should exercise caution when entering into any type of relationship while carefully considering whether counselling issues have been fully resolved or properly terminated. Section B12 in the CCPA (2007) Code of Ethics urges counsellors to avoid any types of sexual intimacies with clients for a minimum of three years after terminating counselling. Counsellors are also responsible for ensuring no exploitative influences have occurred, which is very difficult to prove after therapy has occurred due to the nature of the components of counselling (Schulz, Sheppard, Lehr and Shepard, 2006). Although professional consultation was not sought in this situation, sections B11 and B12 of the Code of Ethics both strongly suggest consultation with other counsellors to determine whether the behavior is ethical (CCPA, 2007).
The first ethical infraction was the violation of boundaries between the client and therapist relationship as it progressed to a romantic relationship. Even an ethical professional relationship can be eroded by several non-sexual boundary crossing behaviors (Schulz, Sheppard, Lehr & Shepard, 2006). In a counselling relationship, clients may feel intimacy and closeness after sharing private details of their life (Schulz et al., 2006). Counsellors demonstrate empathy and unconditional regard may engender strong feelings, which may distort the client’s view of the counsellor (Schulz et al., 2006). Additionally, counter-transference can compliment transference and the counsellor may have a transfer of feelings, thoughts and behaviors stemming from the counsellor’s life experiences (Schulz et al., 2006). Due to the nature of the professional relationship between the client and the counsellor, the possibility of an exploitative relationship is highly probable.
Ultimately, it appears as if the therapist decided to terminate counselling after deciding to peruse a romantic relationship with the client. The therapist may have realized his/her competence was diminished due to the dual relationship however; perusing the romantic relationship was an ethical violation since this secondary relationship could have been avoided. The CCA (2001) Standards of Practice prohibits counsellors from being sexually intimate with clients even after three years if there is a possibility the post-termination relationship originated in the counselling relationship. Even if three years had passed, the counsellor’s decision would have been unethical because the relationship originated in the counselling relationship.
Many issues in counselling may have not been resolved and therapeutic termination was not likely complete especially because the termination occurred with the intention to enter into another type of relationship. The client may be highly vulnerable to the therapist and a high potential of exploitation exists. Dual relationships differ in the severity of potential detrimental consequences and an outside relationship that may initially appear innocent may have damaging consequences. Clients often see counselors in their most vulnerable state, they may have a different perception of the counsellor (even after issues have been resolved), and one cannot guess future ramifications (Schulz, Sheppard, Lehr & Shepard, 2006). Similar to other individuals in helper positions, it is very important to recognize that clients may view counsellors very differently than the average person even years after counselling. The altered perception of the client yields a high potential for an exploitative relationship.
The CCPA (2007) Code of Ethics prohibition of sexual relationships for a minimum of three years after termination is to prevent termination of counselling due to a relationship established in counselling. Overall, the CCPA (2007) Code of Ethics is based on beneficence, fidelity, nonmaleficence, autonomy, justice and societal interest, which serve to act in the best interests of the client. Dual relationships especially with sexual intimacies involved have a high potential for sever ramifications even if the intentions of the relationship are innocent and the CCPA (2007) Code of Ethics principles are not upheld. Ultimately, I believe the therapeutic relationship takes priority over any types of relationships and it is critical to maintain the integrity of the counselling relationship.
Canadian Counselling Association (2001). Standard of practice for counsellors. Ottawa,
Canadian Counselling and Psychotherapy Association (2007). Code of ethics. Ottawa
College of Alberta Psychologists. (2006). Consent for minor clients. Edmonton: Author.
College of Alberta Psychologists. (2002). Standards of practice.
Schulz, W.E., Sheppard, G.W., Lehr, R., & Shepard, B. (2006). Counselling ethics:
Issues and cases. Ottawa, ON, Canada; Canadian Counselling Association.
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