Question that must be considered by those working with multiple participants is, how do standard practices of confidentiality translate from the traditional dyadic client-therapist relationship to a therapeutic relationship that includes a spouse, other family members, or “strangers” in a group? Consider a situation in which a therapist is working with a couple experiencing marital conflict and as part of the treatment, meets with each member privately for one session. During the session with one spouse, that member discloses having an affair. If the therapist believes the affair is contributing to the couple’s difficulties, should the therapist reveal that information during the couple’s joint sessions? What if the individual specifically asks that it not be revealed? Exercise 13.2 provides you with a scenario experienced by one marriage counselor. Reviewing the case will allow you to reflect upon the ethical challenges encountered when working in this modality. Exercise 13.2 In a Bind Directions: Review the following case illustration and then, along with a colleague or a supervisor, discuss your position on each of the questions posed. The Case As part of her marriage and family practice, Dr. Martin schedules individual sessions with the individual members of the couple. In her session with Mrs. Francisco, she discovered that Mrs. Francisco, while attending the sessions, was truly not invested in saving the marriage. In fact, Mrs. Francisco shared that she had begun developing an emotionally intimate relationship with a colleague, who has directed her to a divorce attorney. In the individual session, Dr. Martin was able to convince Mrs. Francisco of the benefit of sharing, in the couple session, her interest in ending the marriage. Although she agreed in the individual session with Dr. Martin, when it came to the joint session, Mrs. Francisco hedged, stating, “I am not sure if this will work—I mean, I’ll come, but I’m not real hopeful … I just don’t know.” When Dr. Martin asked if she could elaborate on her feelings and what it is that she felt was contributing to lack of hope, Mrs. Francisco became somewhat agitated and defensive and stated that she wasn’t sure and that she would give it some thought for future sessions. Given the information previously shared with Dr. Martin in the individual session, this response seemed less than honest and forthcoming. However, Mr. Francisco seemed accepting and encouraged that his wife would continue to think about it and come to sessions. Dr. Martin felt like he was in a bind. For Reflection How would you respond if you were in Dr. Martin’s position, and specifically, how would you respond to each of the following? • Should the therapist push the client to more fully and more honestly disclose? • • • • Would disclosure at this time be what was best for each individual or for the couple as an entity? Should the therapist meet with Mrs. Francisco again to confront her failure to disclose honestly and to discuss the value of a full disclosure? What “rules” would you have established and shared as part of gaining informed consent prior to holding individual sessions? Would doing or saying nothing be ethical? The issue of handling private or “secret” disclosures, as encountered by Dr. Martin (see Exercise 13.2) is complicated and something a practitioner working with couples, families, and/or groups needs to consider prior to engaging with clients. The challenge of course is finding ways to balance the individual’s right to privacy with the relationship’s need for safety, which requires more transparency. It is generally recognized that individual disclosures should be held in confidence only if doing so DOES NOT contribute to maintaining unhealthy family dynamics. The IAMFC, for example, notes, “Couple and family counselors do not maintain family secrets, collude with some family members against others, or otherwise contribute to dysfunctional family system dynamics” (2011, Section B., p. 219). Likewise, the AAMFT takes the following position: When providing couple, family or group treatment, the therapist does not disclose information outside the treatment context without a written authorization from each individual competent to execute a waiver. In the context of couple, family or group treatment, the therapist may not reveal any individual’s confidences to others in the client unit without the prior written permission of that individual.” (2015, Standard 2.2) While there is no one single position on the above, those engaged in family, group, or couple work may find the first step in addressing the sharing of “secrets” to rest in their position on whether they treat members as individual clients and maintain private communication or see the couple, family, or group as client. It can be argued that treating each member as an individual client can encourage privacy and triangulation. The alternative position would be to allow all members, by way of informed consent, to understand private communication would not be encouraged and would not be held in confidence. In either case, a “safe” position for all practitioners would be to inform all participants of the therapist’s stance and practice regarding the maintenance of confidential information. Limits to Ensuring Confidentiality The importance of providing participants this information has been emphasized by our professional organizations. Psychologists who provide services in a group setting, for example, are directed to describe “at the outset the roles and responsibilities of all parties and the limits of confidentiality” (APA, 2010. Standard 10.03). The ACA not only supports a similar position but also directs counselors to “discuss expectations and limitations of confidentiality” and “seek agreement and document in writing such agreement among all involved parties regarding the confidentiality” (2014, Principle B.4.b). The AAMFT Code of Ethics directs therapists to be upfront with the family from the beginning of treatment to inform them of their right to confidentiality and let them know that a therapist may not disclose to other family members any information an individual family member might share in private (2015, Principle 2.1). For individuals working in a group therapy context, the IAGP directs its members to not only respect the participants’ privacy and keep information about participants in confidence (2009, Principle 3.1) but also inform participants “of the limits of confidentiality” (2009, Principle 3.4). It has been suggested that group leaders have members of a group complete a confidentiality agreement, an agreement that explains that comembers have no confidentiality privilege, along with the need to avoid socializing outside of the group (MacKenzie, 1997). Concerns about maintenance and limitations to confidentiality extend to the creation and maintenance of session notes. Would, for example, one family member or one member of the couple have the right to request and utilize family session notes in a lawsuit against one of the other family members? The IAMFC directs practitioners to share that which is unique and personal to the individual requesting notes “in situations involving multiple clients, couple and family counselors provide individual clients with parts of records related directly to them, protecting confidential information related to other clients who have not authorized release” (Hendricks, Bradley, Southern, Oliver, & Birdsall, 2011), a point that is supported legally by the HIPAA standards, which requires that each individual have his or her own records, notes, consent, and other individual data. Maintaining Confidentiality For those who work with couples and families, there can be no absolute guarantee of confidentiality, since unlike the therapist, other participants are NOT bound by a professional ethic directing confidentiality. Encouraging members to respect the privacy of all involved and uphold the spirit of confidentiality does not automatically equate to members’ actions. Because of this, some have suggested enforcing confidentiality with the possibility of termination from the therapy. While this is not feasible in couples or marriage therapy, the International Association for Group Psychotherapy and Group Processes (IAGP) directs its members “to take steps to intervene with group members who violate the confidentiality of another in order to restore a sense of safety to the group” (2009, Principle 3.8). It has even been suggested that therapists take a position of enacting expulsion from the group as a possible consequence in the violation of confidentiality (Brabender, 2002). It is our position that, prior to adopting such a position, it is important to understand the ethical principles guiding “termination” along with a consideration given to the potential impact that such a termination may have on the individual and the remaining members of the group (See Table 13.2).
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