心理学Essay格式：Ethical Importance of Confidentiality in Counselling

本文是心理学专业的留学生Essay范例，题目是“Ethical Importance of Confidentiality in Counselling（咨询保密的伦理重要性）”,心理学家在法律和道德上有责任保护他们所照顾的病人的信息的机密性。每个病人都有权利知道他们与他们的治疗师分享的一切将保持机密，除了在一些关键领域，机密可能必须被打破。治疗建立在信任的基础上，而信任的第一层就是保密，保护客户的私人信息，以及治疗师和客户之间就保密达成的协议。

Introduction 介绍

Psychologists have a legal and ethical duty to safeguard the confidentiality of information concerning the clients in their care. Every patient deserves the right to know everything they share with their therapist will remain confidential, except in a few key areas where confidentiality may have to be broken. Therapy is built on a foundation of trust, and the first layer of that foundation is confidentiality, the protection of the client’s private information, and the agreement between the therapist and the client regarding that confidentiality.

According to Gustafson and McNamara (1987), a central focus of therapy is the establishment of the relationship of trust between client and therapist, and it must be vigilantly protected during the course of the therapeutic practice. Without the conditional promise of confidentiality between the clinician and client, which allows the latter to make full and candid disclosure, the therapeutic alliance may be affected or harmed, and healing may be hindered. Therefore, it is the ethical obligation of psychologists to understand confidentiality within the therapeutic relationship, its limits, and what might occur when, and if confidentiality is broken.

Confidentiality Defined 机密性定义

Confidentiality is one of the most significant components of a therapeutic relationship. The therapist possesses the task of balancing the client’s rights with the legal and ethical obligation to protect client, as well as adhering to the legal and ethical standards of practicing therapy (Isaacs & Stone, 2001). Confidentiality has not changed much over the last few decades, in fact, Shah (1970) stated that a client should be able to use their privilege to guarantee that private communication will not be breached unless the information falls into the few specific categories which are mandated by law. After Shah, confidentiality has been more clearly defined within the APA Ethical Code, which now contains 31 ethical standards related to confidentiality, with 7 of those in the Confidentiality and Privacy Sections.

保密是治疗关系中最重要的组成部分之一。治疗师的任务是平衡客户的权利与法律和道德义务，以保护客户，以及坚持法律和道德标准的实践治疗(Isaacs & Stone, 2001)。在过去的几十年里，机密性并没有改变多少，事实上，Shah(1970)指出，客户应该能够使用他们的特权来保证私人通信不会被破坏，除非信息属于法律规定的少数特定类别。在Shah之后，《美国心理学会伦理准则》中对保密性有了更明确的定义，该准则现在包含了31个与保密性相关的伦理标准，其中7个在保密性和隐私部分。

APA 4.01 (Ethical Code of Conduct) makes this statement regarding confidentiality: “Psychologists have a primary obligation and must take reasonable precautions to protect confidential information obtained through or stored in any medium, recognizing that the extent and limitations of confidentiality may be regulated by law or established by institutional rules or professional or scientific relationships.” It is essential to recognize that confidentiality is not just limited to what is spoken aloud, but also pertains to what is written or typed. It is a therapist’s job to know what the ethical floor is regarding confidentiality but reach for the ethical ceiling.

A second important aspect of defining confidentiality is its limits. While each psychologist should have personal limits to confidentiality, the APA 4.02 mandates that there are certain instances when confidentiality must be broken. The Code dictates that before breaking confidentiality, the “Psychologists should discuss with persons and organizations with whom they establish a scientific or professional relationship (1) the relevant limits of confidentiality and (2) the foreseeable uses of the information generated through their psychological activities.”

定义机密性的第二个重要方面是它的局限性。虽然每个心理学家都应该有保密的个人限制，但APA 4.02规定，在某些情况下，保密必须被打破。守则规定，在违反保密规定之前，“心理学家应与与他们建立科学或专业关系的个人和组织讨论(1)保密的相关限制(2)通过心理活动产生的信息的可预见用途。”

This discussion should occur at the outset of said relationships, and the conversation should continue throughout therapy. Clients should be made aware prior to receiving therapy, that confidentiality will be broken in four cases: First, if there is an imminent danger to themselves or others, second, if there is any child or elder abuse, third, if there is any downloading, streaming, or accessing of media in which a child is engaged in a sexual act, and fourth, if there is a court order demanding a release of information. In all other cases, the therapist would need a release of information from the client before disclosing any information regarding the sessions.

It is imperative that the therapist communicates the parameters and limits of confidentiality clearly and confirms the client’s understanding. It would be considered unethical to enter into a therapeutic relationship with a client who does not thoroughly understand confidentiality.

Literature and Confidentiality 文学和机密性

The majority of research regarding confidentiality has not been updated because it has not changed much over the years. However, two significant events occurred in 1996 that changed the way confidentiality functioned in therapy.

大多数关于保密性的研究都没有更新，因为这些年来它没有太大的变化。然而，1996年发生的两件重大事件改变了保密在治疗中的作用。

The first was Jaffee v. Redmond (“Jaffee v. Redmond,” 2015), which was a case regarding a police officer, Mary Redmond, who shot and killed a man named Ricky Allen. Redmond claimed that she did so to prevent Allen from stabbing another person. Allen’s family sued her for excessive force. After the shooting, Redmond was attending therapy and Allen’s family attempted to obtain the therapy records in hope they would support their suit. Redmond and her therapist, believing they possessed therapist-client privilege, refused to break confidentiality. Still, the trial court found that the Federal Rules of Evidence did not establish the right to confidentiality and instructed the jury they could draw negative conclusions from the therapist refusing to submit therapy notes. The jury found Redmond guilty, and the Allen family won a substantial amount of money. However, the Seventh Circuit court reversed the judgment and ruled that each state had some kind of therapist-client privilege and the Federal Rules of Evidence recognized that indirectly. Upon this reversal, the case was moved to the Supreme Court, at which time, the American Psychological Association intervened stating the importance of therapist-client confidentiality (“Jaffee v. Redmond,” n.d.). This landmark decision outlined the Supreme Courts recognition of the importance of a therapist’s duty to maintain confidentiality within the therapist-client relationship.

The second landmark decision to shape confidentiality was the creation of the Health Insurance Portability and Accountability Act (HIPAA). HIPAA was designed to ensure the security and confidentiality of patient information and data (“When was HIPAA Enacted,” 2019). Individuals determined further regulations regarding confidentiality were required as there were so many undefined areas.

塑造保密性的第二个里程碑式的决定是《健康保险可携性和责任法案》(HIPAA)的制定。HIPAA旨在确保患者信息和数据的安全性和保密性(“HIPAA是什么时候颁布的”，2019年)。个人决定需要进一步制定关于保密的条例，因为有许多未确定的领域。

These two events changed the course of confidentiality in the therapeutic relationship. They allowed for therapists to have the right to deny submitting session records unless the request has been court-ordered. These rulings strengthened the bond and trust between clients and therapists and provided for greater disclosure on the part of the client.

One key piece of literature that discusses all the various aspects of confidentiality is the book The Ethics of Conditional Confidentiality by Mary Alice Fisher (2013).  In her book, Fisher goes over what Conditional Confidentiality means and how to follow it ethically. A vital feature of her writing is to help psychologists decide if they want to maintain absolute confidentiality or conditional confidentiality. Conditional confidentiality is when a therapist chooses to impose limits on confidentiality, as previously mentioned. However, absolute confidentiality implies a therapist will not disclose any information from the sessions, without exception. Absolute confidentiality is not something a therapist should take lightly. If one chooses this route, it cannot be broken when a situation seems complicated. If a therapist chooses to offer their client absolute confidentiality, they need to be sure they have adequate support in this decision, the ability to keep their promise, and most importantly, they are well educated regarding the consequences of refusing to divulge client information and/or records when requested to do so.

A second vital part of Fisher’s (2013) writing is her Ethics- Based Practice Model. She created this model to help put laws into ethical context. This model gives therapists the ethical freedom to create setting specific limits on confidentiality, as long as the clients are informed about these policies in advance and consent to accept them as a condition of receiving therapy. The model contains six steps for a therapist to follow, which are:

Prepare,

tell the truth upfront,

obtain truly informed consent before disclosing information voluntarily,

respond ethically to legal demands for disclosure,

avoid the avoidable disclosures,

and talk about confidentiality.

Step one: Preparing, means that a therapist should take things into consideration even before meeting their client for the first time. A therapist should understand the clients’ rights and the responsibility on behalf of those rights before beginning a session. It is imperative to know the laws that can help or hinder confidentiality in the therapeutic relationship. A therapist should be introspective about what confidentiality means to them, what limits to impose, and how they plan to uphold their values in a session while protecting the client. One should also develop a plan on how to act ethically when involuntary disclosure may be necessary. Lastly, a therapist must be prepared to discuss all of this in a language that is understandable to the client. One should not overwhelm or use technical jargon because the goal is to have the client understand what is confidential, what is not confidential, and feel comfortable disclosing any information.

Step two: Telling the clients the truth upfront is extremely significant, as unclear or inconsistent communication can break the trust and damage the therapeutic relationship. This, in turn, can hurt your practice as it may become known that you are not honest and go back on your word. Effectively telling the truth means informing clients of limits, explaining possible potential conflicts, and making sure the client agrees to the terms. A therapist should make sure that this conversation continues throughout therapy and adjust as needed. Confidentiality is not just a piece of paper or a simple agreement, but a journey to be made with the client throughout the therapy process.

第二步:直接告诉客户真相是非常重要的，因为不清楚或不一致的沟通会破坏信任，损害治疗关系。这反过来又会损害你的实践，因为它可能会让人知道你是不诚实的，而且会反悔。有效地告诉客户真相意味着告知客户限制，解释可能的潜在冲突，并确保客户同意条款。治疗师应该确保这种对话在整个治疗过程中持续进行，并根据需要进行调整。保密不仅仅是一张纸或一个简单的协议，而是在整个治疗过程中与客户一起完成的旅程。

Step three: Obtain truly informed consent before disclosing information voluntarily. This involves assuring the client comprehends precisely what information will be disclosed, discussing the implications of disclosing, documenting the client’s consent to the disclosure through a Release of Information form. Finally, be aware that although a client’s signature has been obtained this may not mean the client is truly informed about what will be discussed. Step three needs to be kept at the forefront of a therapist’s mind because clients have a fear of losing control over the process and they worry about having no say in the matter of disclosure (Jenkins, 2010). The therapist can eliminate this fear by providing clear communication regarding confidentiality.

Step four: Responding ethically to legal demands, which includes knowing how to disclose without harming the patient. The gold standard of therapy is always to do no harm, so one must understand the way to accomplish this task, both ethically and legally. One clarification important for therapists to know is that subpoenas are not court orders. This means that if a therapist is given a subpoena that was issued without a judge’s knowledge, then the therapist does not have the responsibility to disclose information. A therapist should always protect confidentiality rights to the extent legally possible and use protective laws when appropriate. If considering civil disobedience first determine there are no other available options.

第四步:从道德上回应法律要求，包括知道如何在不伤害病人的情况下披露。治疗的黄金标准总是不做伤害，所以一个人必须了解如何完成这个任务，道德和法律上的。有一点很重要，治疗师必须知道，传票不是法庭命令。这意味着，如果在法官不知情的情况下给治疗师发了传票，那么治疗师就没有责任披露信息。治疗师应该始终在法律可能的范围内保护保密权利，并在适当的时候使用保护性法律。如果先考虑公民不服从决定没有其他选择。

Step five: Avoid the avoidable disclosures. Step five is fundamental because not only can a therapist be brought to court for unintentional breaches of confidentiality, it also damages the relationship between the client and therapist. It is not a therapist’s right to decide that disclosure is harmless just because they do not feel the client will be adversely affected.  The core ways a therapist can avoid unintentional disclosures is by avoiding dual roles, protect client identity in presentations and consultations, prepare a professional will in the event of illness or death, maintain protective policies, and create boundaries with friends and family. Doing these things will limit the chances of unintended disclosures and better protect your client and their confidentiality.

Lastly, step six: Talk about confidentiality. This is probably one of the most significant steps in this model because if one cannot talk about it, how can one enact it? Talking about confidentiality-related issues allows the therapist to better develop their position and limitations. Confidentiality should never become a taboo topic but one that is openly discussed in consultation, during graduate courses, when making and enacting policies, and within the therapeutic relationship.

Confidentiality is the rule, and it is unethical for therapists to try and find rationalizations for making exceptions to this rule just to be able to disclose information (Fisher, 2013). Following this model will allow a therapist to better maintain confidentiality, ensuring there are no misunderstandings during sessions, research, and consultations.

Implications for Ethical Practice 对道德实务的影响

Confidentiality as an ethical principle implies an understanding to not reveal anything about the client except under certain circumstances that are understood and agreed upon by both parties (Koocher & Keith-Spiegal, 2017).  A therapist can act ethically in regards to confidentiality by instead of viewing it from the perspective of therapist self-protection; view it from the standpoint of protecting the patient first (Fisher, 2013).

作为一项道德原则，保密意味着除非在双方理解和同意的特定情况下，不得披露客户的任何信息(Koocher & Keith-Spiegal, 2017)。治疗师可以采取道德行为，而不是从治疗师自我保护的角度来看待它的保密;首先从保护病人的角度来看待它(Fisher, 2013)。

Confidentiality is implicitly expected when entering into a therapeutic relationship, and when that expectation and trust is broken, it leaves the client distraught and possibly in worse condition than when they began therapy. Due to lost confidence, many clients will take action, so as to make themselves feel better and to protect others from experiencing the same. When this happens, the therapist may have to face disciplinary action and appear before the court and have to try and justify why they broke confidentiality. If their explanation is not seen as appropriate, then the therapist may lose their license and be unable to practice. If the courts rule the breach of confidentiality as being illegal and unethical legal action may be taken against the therapist, they may face lawsuits because the confidentiality breach may be considered defamatory, business closure, and even incarceration. However, even if the aforementioned extreme results do not occur, any violation of confidentiality when not disclosed or approved by the client first leads to loss of respect and trust. Not only will you lose the respect and trust of your colleagues, but most importantly, you will lose it from your clients, for whom you are there to protect and create a safe environment. Many clients enter therapy after experiencing broken trust, the onset of distressing symptoms, or with the need to talk about their situation with an individual they can trust. When that trust is broken, it may serve as validation to the client that they are not worthy of trust and respect.

Psychologists must remember that confidentiality can change based on the setting and the client. Whether one is working with a group, a family, the elderly, an adult, adolescent, or child, the way confidentiality works will change. It is essential that the psychologist recognizes the differences and makes sure to adjust accordingly.

For these reasons, confidentiality is imperative to the health of the therapeutic relationship.

Conclusion 结论

Maintaining confidentiality in a therapist-client relationship has been an ethical necessity for decades (Gustafson & McNamara, 1987).  Such an agreement benefits the therapist, the client, the therapeutic relationship, and helps to foster trust and respect.  One of the jobs of the psychologist is to balance what is legally mandated and what is therapeutically and ethically correct (1987).  Ensuring the client fully understands the meaning and constraints of confidentiality will allow the therapist to maintain an ethical practice while simultaneously providing a safe and healing environment for the client. Remember the therapist who most often makes mistakes is not the one who takes reasonable, responsible action and can justify their behavior based on the legal and ethical standards, but the one who chooses to do nothing as they are afraid of making a mistake (McCrudy & Murray, 2003). Do not allow fear to dictate the parameters of your therapeutic relationship. Rather, be clear on the laws and ethical standards, by which psychologists are bound. Identify and know well, the best ways to compassionately and justly protect your client’s privacy, mental health, and well-being. Only after accomplishing these vital tasks, can one refer to themselves as an ethical practitioner.

几十年来，在治疗师与客户的关系中，保持保密一直是一种道德上的必要性(Gustafson & McNamara, 1987)。这样的协议有利于治疗师，客户，治疗关系，并有助于培养信任和尊重。心理学家的工作之一是平衡什么是法定的和什么是治疗和道德上正确的(1987)。确保客户充分理解保密的含义和限制将允许治疗师保持道德实践，同时为客户提供一个安全和愈合的环境。记住，最常犯错的治疗师并不是那些采取合理、负责任的行为，并能根据法律和道德标准为自己的行为辩护的人，而是那些因为害怕犯错而选择什么都不做的人(McCrudy & Murray, 2003)。不要让恐惧左右你们的治疗关系。相反，要清楚心理学家所遵循的法律和道德标准。明确并了解以同情和公正的方式保护客户隐私、心理健康和幸福的最佳方法。只有在完成了这些重要的任务之后，才能把自己称为道德实践者。

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