SOCW 6520 Assignment: Week 2 Blog

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Refer to the topics covered in this week’s resources and incorporate them into your blog.

Post a blog post that includes 300 to 500 words my field experience is going to be at Sound options in Tacoma Washington

Questions in bold then answers

An explanation of potential challenges in adhering to confidentiality in your field education experience

A description of agency policies or mandates with regard to confidentiality

An explanation of potential challenges in communicating with clients within your agency

You may choose to support your blog posts with specific references to this week’s resources. Be sure to provide full APA citations for your references.

Week 2 – Confidentiality

Week 2 – Confidentiality
Program Transcript

Developing the necessary skills to realize the distinctions between confidentiality
and open lines of communication is the focus of this week. Maintaining
confidentiality is important when engaging social work clients. Breaking it could
potentially constrain the open lines of communication. For example, consider the
limitations “duty to warn” presents. As a future social worker, how might you
ensure that you are demonstrating social work practice skills while maintaining
confidentiality?

How you communicate also may affect your relationship with other social workers
or even your field instructor. Does your agency observe additional types of
confidentiality when interacting with others?

Week 2 – Confidentiality
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Journal of Human Behavior in the Social Environment

ISSN: 1091-1359 (Print) 1540-3556 (Online) Journal homepage: https://www.tandfonline.com/loi/whum20

Self-Determination and Confidentiality
The Ambiguous Nature of Decision-Making

Catherine Saxon MSW , George A. Jacinto LCSW &

Sophia F. Dziegielewski

PhD, LCSW

To cite this article: Catherine Saxon MSW , George A. Jacinto LCSW & Sophia F. Dziegielewski
PhD, LCSW (2006) Self-Determination and Confidentiality, Journal of Human Behavior in the Social
Environment, 13:4, 55-72, DOI: 10.1300/J137v13n04_04

To link to this article: https://doi.org/10.1300/J137v13n04_04

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Self-Determination and Confidentiality:
The Ambiguous Nature of Decision-Making

in Social Work Practice

Catherine Saxon
George A. Jacinto

Sophia F. Dziegielewski

ABSTRACT. This article seeks to further clarify the ambiguous nature
of two of social work’s most important values: self-determination and
confidentiality. Previous research indicates that many ethical decisions
in social work practice are difficult to make; and, many times decisions
are made based on the worker’s values and experiences rather than on
written ethics, laws, and agency policy. To explore this concept further,
an open-ended survey instrument was distributed to 82 social work stu-
dents after completing the required practice classes. The participants
were asked whether they would break confidentiality based on a specific
vignette and describe what decision was made and why. Results indi-
cated that degree level (MSW versus BSW) proved to be a significant
factor related to whether and/or why the respondent would break confi-
dentiality. In addition, students with more paid work experience were
more likely to question the issue of confidentiality and were more likely
to break it. Two issues reflected in the decision-making process involved
ensuring client safety and self-determination. In conclusion, this article

Catherine Saxon, MSW, is affiliated with and George A. Jacinto, LCSW, is Instruc-
tor, School of Social Work, University of Central Florida, Orlando, FL. Sophia F.
Dziegielewski, PhD, LCSW, is Professor and Director, School of Social Work, Univer-
sity of Cincinnati, Cincinnati, OH.

Address correspondence to: Dr. Sophia F. Dziegielewski, PhD, LCSW, Professor
and Director, School of Social Work, 4130 One Edwards Center, P.O. Box 210108.
University of Cincinnati, Cincinnati, OH 45221-0108 (E-mail: Sophia.Dziegielewski@
uc.edu).

Journal of Human Behavior in the Social Environment, Vol. 13(4) 2006
Available online at http://www.haworthpress.com/web/JHBSE

explores possible reasons for breaching confidentiality and pitfalls that
can occur for all professionals in making these types of decisions. Fur-
thermore, it explores the ambiguous nature of problem solving in this
area, and suggests ways that social workers can improve their decision-
making skills. [Article copies available for a fee from The Haworth Document
Delivery Service: 1-800-HAWORTH. E-mail address: Website: © 2006 by The
Haworth Press, Inc. All rights reserved.]

KEYWORDS. Confidentiality and social work, self-determination,
ethics and social work practice, ethics and confidentiality

Many American’s highly value a person’s right to self-determination
and privacy. In fact, “every person has a right to determine for himself
[or herself] when, how, and to what extent he [or she] wants to share (or
have shared) information about himself [or herself] with others”
(Loewenberg & Dolgoff, 1996, p. 76). To maintain a client’s privacy or
confidentiality requires that information learned regarding the client
should not be openly disclosed (Loewenberg & Dolgoff, 1996; Loe-
wenberg, Dolgoff, & Harrington, 2000). Overall, confidentiality can be
a complicated process, since, there are certain circumstances in which
breaching it is sanctioned by both state laws and professional standards.
For example, confidentiality may be breached with or without the cli-
ent’s consent in order to report instances of neglect and abuse. Other cir-
cumstances include times when a client may be a danger to self or
others, or when other compelling reasons exist, such as imminent harm
to a client or if the law requires disclosure. Most professionals agree that
there are situations in which breach of confidentiality is certainly justifi-
able and expected (Dunlap & Strom-Gottfried, 1998; Gothard, 1995).
Yet, the principles that surround maintaining confidentiality are impor-
tant for gaining client trust and support from the client (Edwards, 1999).
Therefore, the purpose of this article is to preview this complex issue
and to examine the variability that can surround making such ethical de-
cisions.

Throughout the years, maintaining ethical practice (including confi-
dentiality) has been at the forefront in the field of social work. So impor-
tant, in fact, that in 1996 the National Association of Social Workers
(NASW) modified the existing version of the Code of Ethics. This was
the first substantial revision in almost 20 years and only the third time

56 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT

the Social Work Code of Ethics had received major revisions through-
out the history of NASW. These changes “significantly expanded ethi-
cal guidelines and standards for social work practice” (Reamer, 1998,
p. 492). The importance and complexity of privacy and confidentiality
is evident since no less than 18 separate paragraphs of the Code of Eth-
ics are devoted to these issues (Dickson, 1998).

The 1996 NASW Code of Ethics provides lengthy standards with re-
gard to privacy and confidentiality, clearly stating that social workers
should “respect clients’ right to privacy . . . and . . . should protect the
confidentiality of all information obtained in the course of professional
service, except for compelling professional reasons” (NASW Code of
Ethics, 1996, Standard 1-1.07, p. 10). A social worker should make ev-
ery attempt possible to adhere to the rules of confidentiality promoting
self-determination, but should also be aware that there are some situa-
tions that should not be kept confidential (Kirst-Ashman & Hull, 1993).
In most cases where maintaining confidentiality is an issue, consider-
ation is needed in order to determine what is “sufficiently compelling to
warrant a breach of confidentiality” (Kopels & Kogle, 1994, p. 2).

As with other decisions made in social work practice, ethical deci-
sions are not usually simple, right or wrong choices made without a
great deal of thought. Instead, they generally involve choosing between
two undesirable actions and neither choice may appear to be the correct
one, yet some considerations will outweigh others. For example, deci-
sions must be made if maintaining the client’s right to self-determina-
tion may actually cause him or her harm (Strom-Gottfried & Dunlap,
1999). In social work practice, ethical decisions often must be made
quickly but with sufficient thought and attention to assure the right de-
cision is made (Levy, 1993; Loewenberg, Dolgoff, & Harrington,
2000). Furthermore, although helpful as a guideline, the NASW Code
of Ethics does not provide specific direction when professional values
clash (Reamer, 1995).

The declared purposes for the Code of Ethics are to espouse ethical
conduct and to control ethical violations by establishing guidelines of
professional behavior (Berliner, 1989; Reamer, 1995). “[The] . . . code
of ethics cannot resolve all ethical issues or disputes or capture the rich-
ness and complexity involved in striving to make responsible choices
within a moral community” (NASW Code of Ethics, 1996, p. 4). In-
stead, a code of ethics describes values, principles, and standards to
which social workers “aspire and by which their actions can be judged”
(NASW Code of Ethics, 1996, p. 4). Although there have been numer-
ous books written regarding the importance of ensuring ethics and val-

Saxon, Jacinto, and Dziegielewski 57

ues, and specifically addressing the issue of self-determination and
client confidentiality, few evidence-based studies specifically address
this issue. The purpose of this study is to explore whether or not social
work students would break confidentiality based on a specific vignette
and their reasons why.

PREVIOUS LITERATURE

After an exhaustive search, it was discovered that two studies in the
area of confidentiality were found that addressed issues concerning eth-
ical dilemmas that arise in the field of social work with both individuals
and groups. A study by Holland and Kilpatrick (1991), conducted in At-
lanta and the surrounding area in 1989, attempted to identify “dimen-
sions of ethical judgment” used by 27 social workers (p. 138). All of the
social workers held Masters degrees in social work and each had a vary-
ing amount of experience in the field. Most of the social workers were
female and all were directly involved with clients. Holland and Kilpat-
rick (1991) contend that in order to appropriately consider ethical di-
lemmas social workers should be aware of, and not discount, their own
as well as their client’s current circumstances. When ethical situations
arise these issues are never simple and interpretation often requires a
“thoughtful content analysis of the participants’ values and commit-
ments” (Holland & Kilpatrick, 1991, p. 138).

The study focused on analyzing various ethical issues that social
workers are exposed to regularly in their duties. In addition to defining,
addressing, and resolving the issues, the participants’ background and
associations were analyzed, as well as any professional happenings that
might have impacted the respondent. An interview format was used to
explore how practicing social workers comprehend and handle ethical
issues and their responses were examined in an attempt to recognize
“common themes and differences regarding these issues” (Holland &
Kilpatrick, 1991, p. 139).

The results of this study identified three dimensions that seemed to be
fundamental to the ways that social workers managed ethical dilemmas.
First, decisions were often based on a continuum ranging from “an em-
phasis on means to an emphasis on ends” (Holland & Kilpatrick, 1991,
p. 139). Reasons given for decisions made ranged from acknowledging
laws and procedures to focusing on gaining positive outcomes for cli-
ents. In the second dimension, social workers made decisions based on
interpersonal orientations that ranged from emphasizing client auton-

58 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT

omy and freedom to stressing the importance of mutuality. For exam-
ple, many respondents emphasized client self-determination over client
safety, while others justified denial of client self-determination in order
to protect the client from hurting him or herself. In the third dimension,
authority for ethical decisions was explored. In this area, responses var-
ied from “reliance on internal or individual judgment to compliance
with external rules, norms, or laws” (p. 140). Many respondents based
their decisions on personal self-direction rather than agency policy, and
other respondents were more likely to follow the policies and laws.

Holland and Kilpatrick (1991) concluded that decisions made re-
garding ethical issues are most likely affected by prior experience, de-
gree of professional, developmental and situational factors that include
the immediate organizational or professional context, the characteris-
tics of their work roles, and the overall organizational culture. In clos-
ing, the authors observed that of the 27 respondents participating in
their study, not one participant referenced the NASW Code of Ethics as
a resource in helping make an ethical decision (Holland & Kilpatrick,
1991).

In a second study, Dolgoff and Skolnik (1996) investigated how 147
social workers make ethical decisions in the group setting. A survey in-
strument was used which consisted of background information and
seven vignettes that all involved competing ethical issues. Each vignette
was followed by an open-ended question, allowing for an explanation
of the action needed to resolve the dilemma. The seven vignettes con-
sisted of ethical dilemmas involving group self-determination, primary
responsibility to client, confidentiality, self-determination, informed
consent, and authenticity. Also included was a list of sources that the
participant would use to assist with the decision-making. The choices
included practice wisdom, Code of Ethics, another professional code,
particular philosopher or religious teaching, book or journal article, or
other sources.

These authors concluded that the primary method used by social
workers in the group setting for making ethical decisions was practice
wisdom, which was highly influenced by contextual elements and per-
sonal values. In addition, the majority of the respondents sought com-
promise solutions rather than a specific yes or no type of answer.
Similar to Holland and Kilpatrick (1991), Dolgoff and Skolnik (1996)
showed limited use of the NASW Code of Ethics to assist with making
ethical decisions and additional instruction on the Code was suggested
to better prepare students for ethical decision-making.

Saxon, Jacinto, and Dziegielewski 59

Although the two studies mentioned above do not specifically ad-
dress confidentiality and self-determination, these previous studies do
address ethical dilemmas in social work practice and how decisions are
made. In the present study, social work students were asked whether or
not they would break confidentiality and how they viewed client self-
determination when presented with a situation where it was believed
that a client was unable to meet his or her own needs and care for him or
herself.

METHODOLOGY

Sample

Eighty social work students at a large Southeastern university were
presented with a case scenario. The students had varying levels of edu-
cation ranging from at the BSW and MSW level, with all participants
reporting that they had taken at least one or more social work practice
class. Five (6%) of the students were first-year BSW students; 21 (26%)
were second year BSW students; 12 (15%) were first-year MSW stu-
dents, and the majority were (n = 44 or 54%) second-year MSW stu-
dents. In terms of gender, the majority (n = 64 or 78%) of the sample
were female, and the remainder of the respondents (n = 18 or 22%) were
male. Participant ages ranged from 20 to 59 years, with the majority 57
or 70 percent between 20 and 29 years of age; 12 or 15% of the respon-
dents were between the ages of 30 and 39; eight or 10 percent were be-
tween 40 and 49 years of age, and five or six percent were 50 to 59 years
old. Only 77 of the 80 respondents answered the question regarding race
with the majority of the sample (n = 61 or 81%) being Caucasian, eight
(10%) were Hispanic, four (5%) being African-American, three (4%) as
Asian, one (1%) as Hispanic/Asian. Additionally, the number of years
of paid social work experience differed among the participants with 79
(of the 80 respondents) answering the question and the majority (n = 47
or 59%) having no paid social work experience. Three (4%) of the re-
spondents reported less than one year of experience, and 29 (37%) had
more than one year.

Case Vignette

The survey instrument consisted of two parts: demographic informa-
tion and the case presentation. Demographic information included the

60 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT

participant’s gender, age, race, education level (years of social work ed-
ucation), and paid social work experience. The case vignette (see Table
1 for copy of vignette) was presented and each participant was asked to
read it. Based on the information contained in the vignette, the respon-
dent was asked to answer with a “yes” or “no” as to whether or not he or
she would break confidentiality. It was made clear in the vignette that
the social worker was concerned that the client would be unable to meet
his own activities of daily living and refused the social worker’s at-
tempts to arrange to get him help. An open-ended response section al-
lowed the respondent to explain why he or she chose yes or no in
response to the vignette. To ensure face validity, the initial case vignette
was pilot tested with four social workers that were asked to complete
and offer suggestions for improvement. Minor changes were made
based on these suggestions. Suggested changes included: gathering in-
formation regarding the academic level of the social work student, the
number of years of paid social work experience, and more space for re-
spondents to explain why they chose yes or no to the vignette.

Procedure

One hundred copies of the vignette were made and distributed in the
Spring 2001 semester to 100 social work students who were required to
attend a school-sponsored job fair. Of the 100 surveys distributed, 80

Saxon, Jacinto, and Dziegielewski 61

TABLE 1. Vignette

Mr. P is a 78-year-old man who has just been discharged from the hospital. He lives in an
apartment by himself. His brother lives in his own apartment in the same building. You are a
hospice social worker. It is Friday at 3:30 p.m. and you are visiting with Mr. P to complete an
initial psychosocial assessment. During your assessment you conclude that it is not safe for
Mr. P to be by himself because he is unable to meet his own self-care needs. Since he ap-
pears very weak, it is difficult for him to get out of bed on his own and he has no caregiver.
You discuss your concerns with Mr. P. Mr. P appears alert and oriented to person, place, and
time, and strongly declines any assistance. He states that he is not agreeable to move to an
assisted living facility or nursing home. Even if Mr. P agreed to some type of outside assis-
tance, it would be impossible to have services in place in the next two days. You suggest to
Mr. P that maybe his brother could check in with him over the weekend, but Mr. P insists that
he will be fine by himself, and requests that you not inform his brother. His sister, who lives
out of state, will not be available to help for several days. Would you break confidentiality and
ask his brother to check in on Mr. P over the weekend?

Yes______ No______

Please explain your answer.

were completed and returned, equating to a response rate of 80 percent.
Once the completed surveys were collected, the data were analyzed. For
the open-ended responses (qualitative responses), it was necessary to
convert the narrative responses to categorical data that could be ana-
lyzed further. Once coded, each narrative response was examined and
then categorized accordingly.

RESULTS

The vignette required that 80 entry-level social workers complete the
survey and answer with either a “yes” or “no” response. Of the 80 stu-
dent social workers (55 MSWs and 25 BSWs), 37 students (or 46.3%)
stated that they would break confidentiality. The remaining 43 (53.7%) re-
spondents stated that they would not break confidentiality (see Table 2).
This response was broken down further by education level, where the
results showed that 36 percent (n = 20) of the MSW students would not
break confidentiality while the remaining 64 percent (n = 35), however,
would do so. For the BSW students, the results showed that 32 percent
(n = 8) would not break confidentiality while 68 percent (n = 17) would.

The narrative section of the survey allowed the participants to state
why they would or would not break confidentiality. The responses were

62 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT

TABLE 2. Results of the Vignette

Overall results of Vignette
N = 80

Variable
Yes
No

Frequency
37
43

Percentage
46.3%
53.7%

Results of Vignette Based on BSW Students
N = 25

Variable
Yes
No

Frequency
17
8

Percentage
68%
32%

Results of Vignette Based on MSW Students
N = 55

Variable
Yes
No

Frequency
20
35

Percentage
36%
64%

categorized as follows: safety, confidentiality was not broken, social
work ethics, start where the client is and others (see Table 3). The re-
sults showed that of the 80 students responding to the vignette, only 77
chose to explain their answer. As stated above, 37 students chose to
break confidentiality, and, of those, 35 explained their answers. Forty-
three students chose to not break confidentiality, and, of those, 42 ex-
plained their answers (see Table 3).

Of the 77 participants that explained their answers, there was a statisti-
cally significant relationship between students choosing whether or not to
break confidentiality and their explanations (chi-square = 76, df = 6, p =
.001). The majority of respondents (n = 33 or 43%) stated that their rea-
son for breaking confidentiality would be for client safety. One person
(1%) stated that confidentiality would not be broken and 14 (18%) chose
“other.” In addition, 26 students (34%) stated social work ethics and en-
suring client self-determination, and three of the respondents (4%) stated
that they would “start where the client was,” and, since it was not clear

Saxon, Jacinto, and Dziegielewski 63

TABLE 3. Analysis of Responses

Reasons for Answer Based on Answering “Yes” *(N = 35)

Variable
Client Safety
Confidentiality Was Not Broken
Other

Frequency
33
1

Percentage
94%
3%
3%

*Two individuals said yes but did not explain their answers.

Reasons for Answers Based on Answering “No” *(N = 42)

Variable
Social Work Ethics/Self-determination
Start Where Client Is
Other

Frequency

26
3

Percentage
61.9%
7.1%
31%

*One individual said no but did not explain the reason.

Overall Sample Reasons Given *(N = 77)

Variable
Client Safety
Confidentiality Was Not Broken
Social Work Ethics/Self-determination
Start Where Client Is
Other

Frequency
33
1
26
3

Percentage
42.9%
1.2%

33.8%
3.9%

18.2%

*Of the 80 individuals in the sample, 3 participants did not give detailed reason for their
decisions. Therefore, subsequent analysis of the reasons was calculated on an N = 77.

whether this meant enhancing self-determination, it was left as a separate
category.

When explanations as to why one would (or would not) break confi-
dentiality based on the vignette were analyzed separately using a “yes”
or “no” response, the results varied. The overwhelming majority of stu-
dents (n = 33 or 94%) who responded “yes” to the vignette and ex-
plained their answer, stated that their reason for breaking confidentiality
was due to client safety. One student stated that telling the client’s
brother about the situation would not be breaking confidentiality, and
the remaining student’s (n = 1 or 3%) answer was coded as “other.”

There were 43 respondents who answered “no” to the vignette and, of
those, 42 explained why. Twelve respondents (29%) stated that based
on social work ethics such as self-determination was the reason they
said “no” and 14 students (33%) indicated specifically that self-deter-
mination was the only reason. Three (7%) of the respondents gave the
reason for not violating confidentiality as “they needed to start where
the client was” and 13 participants (31%) stated other individual or
non-specific reasons.

After analyzing the data for correlations between the respondent’s
gender and age and whether the answer to the vignette was “yes” or
“no,” no significant difference was found. However, a significant dif-
ference was noted between the level of social work education and
whether or not they would break confidentiality (Chi-square = 10.29,
df = 3, p = . 01). In this regard, the students in the second year of either
the BSW or MSW program were more likely to question the issue of
confidentiality and break confidentiality in regard to this case. A signifi-
cant difference was also noted with regard to the number of years of
paid experience a student had and whether or not they would break con-
fidentiality (Chi-Square = 17.68, df = 8, p = .02). Students with more
experience were more likely to question the issue of confidentiality and
were more likely to break it.

DISCUSSION

This presentation of a potential problem often confronted by social
workers exemplifies the variation in response patterns that can occur
among beginning professionals. Regardless of the level of education,
graduating social workers read the case and used their individual ethi-
cal decision-making methods to develop their answers. Although the
majority of social work students agreed that they would not break con-

64 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT

fidentiality (n = 43 or 53%), a significant number stated that they
would (n = 37 or 47%), especially if it meant ensuring the safety of the
client. Given that these respondents were almost evenly divided about
how best to respond to this situation, it appears that for these begin-
ning social work professionals, confidentiality was not a “yes or no”
issue. When confronted with certain situations in the field of social
work, deciding what constitutes client self-determination, ensuring
client safety and what should remain confidential can be difficult and
can present an ongoing struggle for even the seasoned social work stu-
dent.

The findings regarding the reasons why social work students chose to
either break or not break confidentiality were varied. Of the 35 students
who chose to break confidentiality and explained why, 95 percent (n =
33)–an overwhelming majority–stated that ensuring “client safety” was
the reason. Based on the vignette, they decided that the client was in
danger and a breach of confidentiality that could involve a report to the
appropriate agency to ensure client safety and protection would be ap-
propriate.

On the other hand, those who would not break confidentiality offered
various reasons, and the responses heavily related to ethical principles
such as ensuring client self-determination. Twenty participants be-
lieved that client self-determination was more important than breaking
client confidentiality. Three participants stated that it was important to
start “where the client is,” and therefore respect client self-determina-
tion. The remainder of the participants in this area–20 social work stu-
dents–would not break confidentiality, as they felt this was critical to
the helping relationship and other ways of helping the client were sug-
gested.

According to these respondents, social work values and ethics can be
perceived as ambiguous within certain situations, especially those in-
volving conflicts between client self-determination versus client safety.
While self-determination and safety were concerns shared by some re-
spondents as a reason for maintaining confidentiality, there were no fol-
low-up questions that analyzed these concerns in depth. Therefore,
further research that addresses the reasoning of practitioners in explor-
ing the multifaceted issues associated with client safety and self-deter-
mination would contribute important insights to this discussion. The
ambiguous nature of this type of work is further complicated by deci-
sions in regard to confidentiality and ethical practice. Therefore, the de-
cisions social workers can confront on a daily basis in practice are not
necessarily simple and straightforward (Loewenberg, Dolgoff, & Har-

Saxon, Jacinto, and Dziegielewski 65

rington, 2000). This study is similar to findings by Holland and Kilpat-
rick (1991) and Dolgoff and Skolnik (1996), concluding that many
decisions social workers make are primarily based on their own per-
sonal values and life experiences. Similar to previous studies, social
workers in this study did not appear to be truly “objective” and
“non-judgmental” and in reviewing the open-ended comments, it was
common for the explanations of the decisions made to be directed, at
least in part, by personal experiences and values. This makes being
aware of one’s values and experiences and how it may influence ethical
decision-making crucial.

Education in the field of social work at the BSW and MSW level ap-
peared to be related to decision-making. Furthermore, it appeared that
the level of education (either BSW or MSW) impacted whether or not a
social worker would be more inclined to question the issue of confiden-
tiality. Significant differences between education level and breaking
confidentiality differentiated first-year and second-year BSW and
MSW students. In looking at the qualitative responses, the second-year
BSW students and the second-year MSW students were more likely to
question the issue of confidentiality and break confidentiality when
compared to the first-year students of both the Bachelors and Masters
levels. Although the exact reason for this difference cannot be deter-
mined, one possible reason is the increased exposure to ethical dilem-
mas in the classroom and field placement experiences. Many times
instructors, especially in the second year of the BSW or MSW program,
present vignettes related to ethical dilemmas that may also be found in
the field setting. These dilemmas are generally discussed at length and
this allows for the students to hear varying opinions while problem
solving within the group setting. This can allow additional opportunity
for students to experience social work practice as it really is, and not
simply review how it has been portrayed in textbooks.

It is important to note that there was little difference between the
MSW and BSW students’ responses to the survey. In this study, 36 per-
cent of the MSW students and 32 percent of the BSW students upheld
confidentiality. While 64 percent of MSW students and 68 percent of
BSW students stated they would breach confidentiality. Both BSW and
MSW students reported they would uphold confidentiality approxi-
mately one third of the time. It is important to note that by a significant
majority BSW and MSW students reported they would breach confi-
dentiality.

A final item worthy to note, based on subject feedback, was that dur-
ing the administration of the survey many Masters-level social work

66 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT

students voiced difficulty in trying to answer the vignette. Masters-level
students voiced the need to analyze the vignette and would try to ask the
researcher questions, requesting clarification on various aspects of the
case. It appeared difficult for them to simply read the vignette, answer
the question and give an explanation. One of the explanations for this
could be the level of critical thinking taught at the Masters level. In con-
trast, almost all of the Bachelors-level social work students seemed to
have no difficulty accepting the survey at face value and completing it.

If this study were to be reproduced there are several considerations
that would be suggested. First, the sample was limited to only one
school of social work and it would be interesting to see how this school
compared with others across the United States. Second, this survey did
not ask respondents to say what sources they utilized to approach the
ethical situation. In analyzing the data, it would have been more com-
plete had that information been available to compare to the previous
studies. This data would possibly have offered reasons as to why educa-
tion level seemed to be significant in choosing “yes” or “no” to the spe-
cific vignette. It would also be interesting to compare these student
responses with other students in the helping professions. Similar to pre-
vious studies, the social workers in this study did not mention the Code
of Ethics in the decision-making process, but did mention ethical princi-
ples. It would be interesting to see if these ethical principles were de-
rived directly from the NASW Code of Ethics.

When looking specifically at issues in client confidentiality and self-
determination, managed behavioral health care has clearly impacted the
practitioner-client relationship (Dziegielewski, 2004, 2002; Loewen-
berg, Dolgoff, & Harrington, 2000). At times, these contractors require
that information be provided that may compromise professional stan-
dards of confidentiality. These student social workers may be placed in
a dilemma regarding the NASW Code of Ethics and the contradiction
encountered with information disclosure procedures of managed care
organizations (Loewenberg, Dolgoff, & Harrington, 2000; Strom-
Gottfried, Kimberly, & Corcoran, 2000). In addition, technological ad-
vances utilized in current practice stress the reliance of the industry on
utilization reviews through increased use of electronic data collection
and storage which has put the confidentiality of client information at
risk (Strom-Gottfried, Kimberly, & Corcoran, 2000). Regardless of the
exact impact of the managed care practice principles and the technolog-
ical advances often employed, the professional decisions made by pro-
fessional social workers are never easy and straightforward. This can
create a new dimension that needs to be factored into an already ambig-

Saxon, Jacinto, and Dziegielewski 67

uous decision-making process where social workers cannot help but be
influenced by either organizational or managerial expectations. These
requirements add a number of complex elements to decisions about re-
leasing confidential information regarding clients.

In this study, many social workers decided to break client confidenti-
ality and report the situation to the appropriate office of adult protective
services. While other participants did not see the situation described in
the vignette as life-threatening therefore it did not need to be reported.
What complicated this analysis further was how social workers inter-
preted the legal system, and the laws that govern practice. This lack of
continuity in itself can make social workers ambivalent about the appro-
priate response in extreme cases. Not only is there ambivalence and
confusion among practitioners, courts across the country have also had
difficulty in regard to decisions about the duty to warn. For example, the
Tarasoff case (1976) has lead to differing interpretations of the relation-
ship of a therapist and client. This confusion becomes obvious when the
Florida court, in the case of Boynton v. Burglass (1991), differed from
the California court in the Tarasoff (1976) decision. In this case, a psy-
chiatrist named Dr. Burglass had been treating Lawrence Blaylock as an
outpatient. Blaylock shot and killed Wayne Boynton, Jr. and Boynton’s
parents sued Dr. Burglass because he had failed to warn the victim that
Blaylock had threatened to seriously harm him. The Court’s analysis
was the first of its kind in Florida and stated that mental health profes-
sionals in Florida do not have a duty to warn the potential victim of
threat posed by a voluntary client. The district court based its decision
on three reasons: (a) the mental health professional does not have the
ability or right to control a client, and cannot be held liable for what a
client does; (b) because the inner workings of the human mind is essen-
tially mysterious, mental health professionals are under no legal duty to
foretell when a client will injure another person; and (c) the court requir-
ing duty to warn would negatively affect the treatment relationship
(Behnke, Winick, & Perez, 2000).

Furthermore, from an organizational perspective, in Green v. Ross
(1997) the Florida court interpreted the language of the law to allow
practitioners to warn, but does not require disclosure of confidential in-
formation to third party or the police of a serious threat by a client. As
social workers struggle whether to honor “duty to warn” by preventing
danger to self or others thereby ensuring safety, confusion remains as
court interpretations around the country differ. It is not surprising that
social workers in this study and otherwise would vary their approaches
to maintaining confidentiality since the legal system remains unclear re-

68 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT

garding disclosure of confidential information (Behnke, Winick, &
Perez, 2000).

Managerial, technological and legal pressures, accompanied with the
ambiguous nature that surrounds when to support self-determination
and not reveal confidential information, may contribute to these begin-
ning professionals’ difficulty in making the most appropriate decision.
Beginning social work professionals may start to believe that regardless
of what they do, information that is disclosed is no longer confidential
and protected. The level of seriousness with regard to the breach of con-
fidentiality in this case might be considered low in comparison to a case
where a social worker is laboring under the decision to warn a potential
victim of a client’s intent to inflict harm; although, it requires use of the
principles involved with more complex cases. Furthermore, social
workers need to clearly discuss with clients the bounds of confidential-
ity and when the social worker is obligated to break it.

To date, there are no simple answers or clear guidelines for the deci-
sion to violate client self-determination or confidentiality. This made
the decision a difficult one for social workers that analyzed this case vi-
gnette and decided to break client confidentiality by asking the brother
to check on him. Maintaining client self-determination and autonomy is
an issue that must be considered and compared with the danger clients
present to themselves by being unable to meet their own care needs
without assistance (Corey, Corey, & Callanan, 1998). As can be seen in
the splitting of this sample, decisions like this, although encountered by
social workers on a daily basis, are never easy. Nor should they be. Each
individual and situation is unique and deserves careful ethical deci-
sion-making.

In closing, the vignette used in this study could be adapted as a teach-
ing tool in which students would reflect on the following questions:

1. What are the ethical issues presented in this case?
2. How does the principle of self-determination apply in this case?
3. List the aspects of confidentiality involved in this case.
4. Mr. P appears to be at-risk for unintended self-harm. Should he be

assessed for involuntary placement since it appears he cannot care
for himself?

5. Explain the ethical problems of confidentiality and self-determi-
nation inherent in contacting Mr. P’s brother against his wishes.

In addition to theses questions, the following assignment can be used
which provides fertile ground for discussion by social work educators

Saxon, Jacinto, and Dziegielewski 69

of the reasoning patterns used by the student to problem solve ethical
decision-making. For each of the following courses of action list a ratio-
nale for selecting and rejecting the action in Mr. P’s case.

1. The social worker decides to respect the principles of confidenti-
ality and self-determination and do nothing.

2. The social worker assesses for involuntary placement due to Mr.
P’s impaired judgment about his current life circumstances.

3. The social worker decides that the least restrictive route is to con-
tact Mr. P’s brother who will check in on him during the weekend.

4. The social worker explains to Mr. P. that you are not convinced he
can attend to his needs and present him with the options based on
your assessment.

5. Based on the above options or others, what course of action would
you favor? (Be sure to give your own rationale for the decision.)

CONCLUSION

As stated earlier, social workers regularly make difficult decisions
that, in many cases, have no “right” or “wrong” answers. This study
supports the contention that important social work values such as client
self-determination, ensuring client safety and maintaining confidential-
ity can constitute an ambiguous process, creating a disjunction between
values and process where there may not be a “correct” answer. This
study reminds educators of the importance of including analysis of per-
sonal values and life experiences as well as social work ethics, laws or
agency policies (Loewenberg, Dolgoff, & Harrington, 2000). If schools
of social work spend little time on ethical content and decision-making,
social work students may be lead to believe that learning about social
work ethics is their responsibility. Lack of information and training in
this area can create a disservice to students that will have ramifications
in terms of decisions and resulting consequences.

The responses to the survey suggest a need for guidelines that social
work educators can use in courses across the social work curriculum.
The development of ethical decision-making skills related to practice
examples is critical for successful practice. The social work educator
may want to use a simple framework to process ethical issues using the
following or similar steps. First, when working with case examples, stu-
dents must first decide what ethical dilemma or dilemmas are present.
Second, check the NASW Code of Ethics to determine what procedure

70 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT

is recommended. Third, review research literature to determine the best
practices related to the issue. Fourth, list the possible ethical responses
to the ethical dilemma. Fifth, order the responses based on their ethical
soundness based on the NASW Code of Ethics, best practices informa-
tion and precedents set in your current work environment. Sixth, project
the likely outcome based on each of the responses that appear appropri-
ate. Seventh, when unsure about the choices, consult with another social
worker about direction. When possible, consult with a supervisor about
the case. Finally, present the option(s) you have chosen to the client.

Barker (2003, p. 387) states “self-determination is an ethical princi-
ple in social work that recognizes the rights and needs of the clients to
be free to make their own choices and decisions.” Self-determination
raises concerns about the client’s participation in case decisions. What
is the capacity of the client to make informed decisions? When present-
ing options to clients it is important to understand the client’s level of
functioning as well as developmental level. The social worker provides
the client with choices discusses resources and explores consequences
of various choices (Barker, 1999).

There needs to be more discussion regarding the NASW Code of Eth-
ics, focusing on how the code can serve as universal resource for poten-
tial ethical dilemmas faced by practitioners. The dearth of empirical
literature regarding the issue of confidentiality suggests more research
is needed. Since practice decisions are rarely based on dichotomous
principles (yes or no answers), future research needs to expand this con-
cept and involve a number of choices over a continuum spanning from
least to most desirable. The continuum fits well with the principle of
self-determination because most individuals prefer selection from two
or more choices when solving complex problems. In this turbulent envi-
ronment, client issues are often complex and multidimensional, and the
greater knowledge and skill a practitioner is able to acquire in ethical
decision-making the better.

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72 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT

Revisiting confidentiality: observations from family
therapy practice

Daniel Paul Wulffa, Sally Ann St Georgea and
Fred H. Besthornb

Confidentiality has long been recognized as a critical legal and ethical
principle for the committed, value-based practitioner. Vital principles
(such as confidentiality) become manifest in material practices and in the
language of professional and societal narratives. This articulation into
specific practices and performances requires a pragmatic process that
transforms the abstract into real-world activities. This imperfect process
has the potential of including the derived practices that in certain ways
may extend the principle in unintended or unwanted directions. In the
case of confidentiality, the actual practices of confidentiality may be both
emancipating and inhibiting – they may protect as well as isolate. Our
purpose is to revisit the idea of confidentiality and to deconstruct the way
it functions in both positive and negative manners in clinical work.

Keywords: confidentiality; societal narratives; community-minded family therapy.

It is never easy to undertake a critical review of a topic that most
people believe to be a fundamental dimension of effective helping.
The principle of confidentiality is one of those ideas that appears to be
so sacrosanct as to be beyond purposeful and serious questioning. Our
view is that critical reflection on any practice strategy, policy initiative
or ethical standard in the helping professions is not only appropriate
but necessary in order to ensure that those practices, policies and
ethics continue to support the goals they were created to meet. ‘It
is quite healthy for a profession and its members to question theory
and operation. Without constant assessment and evaluation, the
profession can become stagnant and antiquated’ (Vesper and Brock,
1991, p. 148). In this article we consider how one of our professional
helping canons – confidentiality – may at times inadvertently serve to

Journal of Family Therapy (2011) 33: 199–214
doi: 10.1111/j.1467-6427.2010.00514.x

a University of Calgary, Faculty of Social Work, 2500 University Drive NW, Calgary,
Alberta, T2N 1N4, Canada. Corresponding author e-mail: dwulff@ucalgary.ca.

b Department of Social Work, University of Northern Iowa, Cedar Falls, Iowa, USA.

r 2010 The Authors. Journal compilation r 2010 The Association for Family Therapy and Systemic
Practice. Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main
Street, Malden, MA 02148, USA.

J O U R N A L O F

FAMILY THERAPY

mailto:dwulff@ucalgary.ca

constrain our work with families and impede families’ own initiatives
for growth.

First, let’s take a moment to reflect upon the conventional notion of
confidentiality. Over time it has tended to become a kind of uni-
versalizing narrative, so accepted and acceptable precluding any need
for critical review or careful reconsideration – it has achieved the
status of a given. When discussing confidentiality the notion of privacy
is often conflated with the notion of confidentiality. But, according to
Clark (2006), ‘[p]rivacy and confidentiality are different qualities: the
one refers to a status while the other refers to the terms of a
communication’ (p. 127). Thus, in practice, we see confidentiality as
a negotiated practice strategy that functions as a means to an end – of
assuring protected patterns of open communication. Vesper and
Brock (1991) point out that ‘the successful clinician encourages the
client to disclose information that may be disconcerting. To obtain
such guarded information, the therapist must be able to assure the
client of strict confidence’ (p. 55). Confidentiality is an arrangement
that a therapist has with a client that invites the client to disclose
sensitive information required by the therapist to conduct effective
therapy, with the proviso that the therapist will not reveal that
information to anyone else.

There can be little doubt that the conventional idea of confidenti-
ality has served an important protective function for individuals and
for many in the larger community. This protective function is not
always advantageous when viewed from the different perspectives of
other cultural traditions or social conventions. ‘[T]he rights to
privacy and to give informed consent that are now so prominent
in Western society may seem quite foreign in cultures that have
fundamentally different views of boundaries between people and
those in authority positions’ (Reamer, 1995, p. 38). Moreover,
Moore-Kirkland and Vice Irey (1981) point out that people in rural
communities, closely knit urban communities and residential set-
tings are ‘intricately related through family ties, historical events,
and high visibility of behaviour’ (p. 320) that make strict confidenti-
ality next to impossible, even if pursued. Indeed, there is a growing
recognition that numerous cultural, religious and regional differ-
ences exist with respect to how privacy and confidentiality have come
to be understood in disparate parts of both the Western and
developing worlds. Despite this, the fact remains that modernity’s
foundational idea of the self-contained, private individual – operat-
ing in a largely private, rigidly demarcated social world and legally

200 Daniel Paul Wulff et al.

protected from unwanted probative inquiry – is closely associated
with how the principles of privacy and confidentiality have come to
be interpreted and applied in Western society (Besthorn, 2002).

There have been frequent efforts in family therapy, social work and
psychology that have stretched the focus of the therapeutic change
beyond the individual client or even the individual family to include
the larger social network of that client (for example, Auerswald, 1981;
Seikkula et al., 1995; Speck and Attneave, 1973).

Speck and Attneave, whose therapeutic approach is dependent upon the
active involvement of a client-family with friends, relatives, work associ-
ates, and others in the natural environment, contend that the lack of
confidentiality contributes to the effectiveness of network therapy. As
channels of communication open within the social network, members
experience relief from sharing private burdens and develop trust in one
another. . . . New information and open communication can present an
opportunity for the total system – family, neighbourhood, and commu-
nity – to develop new ways of dealing with each of its parts on a realistic
basis.

(Moore-Kirkland and Vice Irey, 1981, p. 321)

Efforts to protect an individual’s right to confidentiality have also had
the unintended consequence of privileging certain preferred ther-
apeutic modalities and limiting others. Those modalities that are
grounded in an individual approach and based on securing informa-
tion within a one-to-one therapist–client relationship have been more
accepted, while using modalities that are grounded in a context of
more expansive conversation among larger networks of individuals
have been seen as suspect or problematic.

‘By concealing information . . . [the therapist] defines family and
society as separate entities with conflicts of interest’ (Haley, 1977,
p. 199). Conventional ideas of confidentiality thus become a mechan-
ism to develop and maintain a division between a family in therapy
and the larger context in which they live, encouraging a view that they
represent differing, and sometimes competing, interests. Keeping
clients separated from each other in their own privately constructed
and idiosyncratic worlds also prevents them from coming to know and
learn from each other. This client separation or privacy is derived
from the idea that each family has a problem that is most efficaciously
ameliorated by a therapist behind closed doors. Other families
struggling with similar issues are not considered as resources or
seen as able to offer the kind of significant help that is generally

Revisiting confidentiality 201

understood to be afforded only by a professional therapist. This
situation is not uncommon in family therapy practice, despite the
fact that support groups have a long and rich history in producing
networks of information and mutual support for members that
seriously challenges the notion that people in distress cannot be a
significant resource for others in distress (Steinberg, 1997; Whitaker
and Garbarino, 2005). Additionally, it may well be that this resource
may be as useful to those giving help as it is to those receiving it
(Pilisuk and Parks, 1986).

We have experienced a number of situations over the years in
which carefully circumscribed ideas of confidentiality have, in our
view, been directly associated with prolonging distress and inhibiting
clients and communities from addressing important issues. We have
also experienced situations with clients in which traditional (or usual)
practices of confidentiality work well. We are not advocating a whole-
sale change in how confidentiality is understood and used for all
clients. Simply put, we have seen some situations in which confidenti-
ality was not as helpful as we hoped it would be. In this article we
examine how confidentiality, despite its significant usefulness
in protecting client information and protecting clients from the
consequences of others knowing their personal situation, may be
implicated in restraining families and therapists from reaching
improved levels of health and well-being. The examples that follow
are illustrative.

Should Madeline and Betty meet?

Madeline was a refugee single mother from Colombia with two
adolescents and two younger children. I (SSG) first met Madeline
and her children through a neighbourhood service group dedicated
to helping new refugees settle into our community. Working with a
neighbour, my intention was to help Madeline and her children with
daily activities and to negotiate, successfully, a new life in a foreign
country. I saw the family regularly, provided basic staples of living and
transportation, and became good friends.

Betty was a single mother with three adolescent children of her own
and two young nieces at home; she was of mixed race (Caribbean and
Aboriginal) and I was her family therapist. Betty was unemployed,
poor and lived in crowded housing. She had to rely on public

202 Daniel Paul Wulff et al.

transportation and struggled to keep her children safe, in school and
out of trouble. Managing these children was an enormous task; the
family was preoccupied with issues surrounding developmental
delays, drug experimentation, bullying and discrimination. My clin-
ical work with Betty’s family was primarily in her home but included a
great many collaborative contacts and meetings with other helping
professionals who were also working with this family.

Several months after Madeline’s arrival to Canada she had fallen on
the ice and broken her hip. It was determined that she needed
surgery to correct the injury and so my neighbour and I became
involved in making arrangements for childcare during her hospitali-
zation and recovery. The recovery did not go well as she developed a
serious infection. Madeline was once again hospitalized and her
condition did not seem to improve. In the midst of this major crisis
with Madeline, I decided to ask Betty (an openly religious person who
often spoke of the power of prayer) if she would pray for a sick mom
(Madeline). Betty’s response was an unequivocal yes and, further-
more, she said she would ask her congregation to pray for the sick
mother as well.

Each time I went to Betty’s house she would ask how the sick
mother was doing. Unfortunately, more complications developed and
Madeline’s spirits were sagging, in part because she still had difficulty
with speaking English. Madeline was also a devout woman and I often
told her that she was being remembered in prayer by many people –
colleagues, my family and even some mothers that she did not know.
Madeline believed that was her only hope.

Two weeks after Betty began praying for Madeline she said to me, ‘I
want you to take me to the hospital to be with this sick person. I want
to minister to her’. I was unsure how to respond, and therefore told
Betty that the sick person would need to be consulted as to whether
she was agreeable to the visit or not (figuring that this would give me
time to think about the confidentiality issues involved). When con-
sulted about Betty’s offer, Madeline was delighted and said, ‘Yes, of
course, that would be wonderful’.

Up to this point, I had not revealed the identities of either Madeline
or Betty to each other except in a generic way (a ‘sick mom’ and ‘a
mom raising kids alone who prays for you’). However, they both knew
my profession. On a human-to-human level, I believed that it made
perfect sense for one woman to help care for another. I consulted a
few colleagues who concurred with me, believing that it was non-
sensical to prevent a person from reaching out to help another in such

Revisiting confidentiality 203

dire need. Keeping Betty’s identity confidential became less im-
portant than the potential benefits of these two women meeting.
Madeline would receive support and encouragement and Betty would
benefit from reaching out to help someone. But I was now bringing
together these two women face-to-face, one of whom was a client and
the other a friend.

I anticipated that the meeting would last about an hour. Betty
emerged from her house with a bag that looked much like a medical
bag doctors used to carry when they went to their patients’ homes.
Betty said that she was bringing a candle, ointment, comb and brush,
mints, herbal tea and a prayer book. When they were introduced, the
women talked for a few minutes about how many children they had,
where they were from, and then Betty instructed Madeline to rest and
let her (Betty) do her ‘work’. Madeline closed her eyes and gave herself
over to Betty who, after setting the atmosphere with a candle,
massaged her body with ointment and brushed her hair, all while
praying or humming. I only watched in amazement. Nurses came in
and silently took their monitor readings, not wanting to disrupt. When
the body treatments were complete, Betty proceeded to quietly sing.
Madeline fell into probably the most comfortable slumber she had had
in weeks; Betty packed her bag, left the mints and tea and went out.

Madeline and Betty did not meet again. Madeline improved and
fully recovered. It could have been the medical treatments, the
extraordinary care provided by the nursing personnel, praying,
Betty’s visit, and many other attempts to help. Madeline would
occasionally ask about Betty and say she was praying for her and
her family; Betty would do the same in regard to Madeline.

The church that wanted to help

With a few other colleagues we (SSG and DW) had begun what we
called a ‘public practice’ that we referred to as the ‘Community-
minded family therapy project’. It was a project that allowed us to
work with client families who were slipping between the cracks of
services, or were homeless or marked as failures in the social service
delivery system. As we were not working under the auspices of an
agency or institution our work was wholly informed by ethical guide-
lines, our preferred practices and the clients’ expectations and wishes.

We were lucky to have a church that wanted to help us with our
project by offering us the use of their building space for family or
other collaborative meetings. After a few months we returned to the

204 Daniel Paul Wulff et al.

church board to report on the progress of our work. At this meeting
the parishioners and board members said that they would like to help
our efforts, not only by letting us use their space but in other ways.
They offered their time and their talents. We could and should feel
free to use them to help the families we were serving. Now how would
this fit with confidentiality?

Our group met and we clearly saw that the families we worked with
needed many forms of assistance. They had no transportation, the
children were in need of academic tutoring and the parents were in
desperate need of respite. We saw a church community of people who
had transportation, time and interests that matched those of the
families. So what was our hesitation? We harboured a concern that
joining families who were our clients with volunteer helpers was
breaching the confidentiality of our clients. The confidentiality of our
relationship with our clients and exposing our client families to
volunteers seemed worrisome. Yet, it made so much gut sense to
arrange for these people to come to know each other. Why the
disparity between what our common humanity told us and what
professional confidentiality said? We wondered if broadly held beliefs
or grand societal narratives regarding privacy and confidentiality
were creating a gap between what our hearts told us and what the
professional codes of conduct told us.

We knew that we were not miracle workers who could unilaterally
transform people’s lives and we knew that a time would come when
we would not be in these families’ lives. We began to think of our role
as helping to connect people with people. If we did not have this
worry of keeping clients’ troubles privatized in order to comply with
strict confidentiality, we could feel comfortable with a decision to join
our clients with generous church members. This intersection of
church members’ genuine desire to help and the families’ need for
support systems provided a possibility that could serve the desires and
wishes of both sides.

Clergy sex abuse

This illustration is somewhat different from the preceding two clinical
examples. The reason we include it here is to show how maintaining
confidentiality at micro and macro levels can have deleterious effects
on front-line practice.

During 2002 a series of reports appeared in our local paper that
outlined a widening revelation of sexual abuse incidents involving

Revisiting confidentiality 205

Catholic clergymen abusing children and adult women (Smith, 2003).
These reports revealed a pattern of sexual abuse by local clergy that
had been going on for over 30 years without the knowledge of anyone
but the clergy, clerical administrators and the victims and their
families involved. Because of the shame involved in such incidents
many victims and their families were more than ready to keep the
incidents out of the public spotlight. The church also had a vested
interest in keeping these stories from being more widely known.

Confidentiality protected the secrecy surrounding these incidents
but a by-product of this secrecy was that the community at large was
totally unaware of what was happening in their midst and the context
in which these problems could re-emerge again and again. The
privacy afforded to this situation provided the soil in which the
problem could continue. Only when the public became aware of
the magnitude and frequency of these incidents did the church
respond to take steps to put a stop to further such episodes.

This illustration reveals the difficulty in managing confidentiality in
the individual context when successful management at that level may
produce the context for future abusive episodes with other indivi-
duals. How do we professionally respond to the needs and wishes of
the individual(s) in the immediate case of abuse and simultaneously
avoid contributing to the probability of similar abuses in the future?
The linkage of these two issues (present occurrence and future
probable occurrences) is troublesome but to separate them as if they
were two unrelated issues unfortunately provides a fertile context for
the perpetuation of this problem.

Family therapists who work with families involved with the legal
system on such issues as child abuse or domestic violence face this
public–private dilemma. Maintaining tight confidentiality protects the
privacy of their client (either victim or perpetrator) while simulta-
neously keeping other parties unaware of it, which potentially could
be problematic for them in the future, depending on the success (or
lack thereof) of the therapy. This is not to suggest that therapy should
be opened to the public but to highlight the way in which our current
system of confidentiality is not completely sufficient.

Isolation as an unintended consequence

These three illustrations highlight for us how confidentiality, as
traditionally understood and implemented in our field, can encumber
our thinking and our ability to act as creatively and broadly as we

206 Daniel Paul Wulff et al.

might. In each of these examples we could see and feel the impact of
an unwavering confidentiality standard in restraining information,
relationships and our own thinking; in effect, serving to restrict or
close down ideas and options. In addition to restricting our creativity
we noticed in our two clinical examples a progressive development of
feelings of separateness and isolation. By isolation we mean the sense
of being the only one to experience something; that no one else knows
about one’s troubles and that no one cares. It is not an uncommon
experience to be in close connection with many people but still feel
alone. In his book, The Dark Child, Laye (1994) says it thus: ‘There had
never been so many of us, but I had never felt so alone’ (p. 142).

The three situations we have described have prompted us to
consider how larger policies, practices or discourses or narratives
might be involved in our clinical work. These may facilitate change
but they also might maintain the status quo. We have often heard
colleagues (and ourselves) use terms or concepts such as: self-suffi-
ciency, self-efficacy, independence and ego-autonomy (less frequently)
as unquestioned goals in working with clients. We have began to
wonder whether operating under the metaphor that all clients needed
to be self-sufficient to be successful was contributing to growth or
restraining it. In the light of our current practice, which confirms that
bringing clients together with other people can be helpful, it appears
to us that the conventional notion of confidentiality is built upon the
modern socio-political foundation of autonomy, individualism, sepa-
rateness and self-sufficiency; prominent belief systems for those of us
in the West. This narrative or belief system generally suggests that
people should be free from interference from others and that they
should strive for and be independent in order to be considered
healthy and worthy as citizens and self-actualized as human beings.

Our experiences in practice helped us to question the indepen-
dence–isolation narrative and to wonder if it worked counter to what a
family presenting for therapy most needed. As we raised these
questions we heard our clients’ words replay in our minds: ‘I need
a village’ and ‘I don’t need a six-month intensive program, I need
help all along the way’ and ‘we will never get out of the system because
they think a single mom with no job is not going to be able to support
her family alone’ and ‘are we the worst family you have ever seen?’
and ‘we are a poor family, not a stupid one’ and ‘discrimination
will only let us get so far’. We wondered if these statements high-
lighted what might be considered the shadowy side of confidentiality
and its largely unconscious reliance on powerful Western values of

Revisiting confidentiality 207

independence and autonomy. Each statement reflected to us a
marginalization and a significant sense of isolation.

What if we described the grand narrative of individualism as both a
good thing (self-sufficiency and independence) and as a troublesome
thing (isolation and aloneness)? If isolation were the tarnished side of
the individualism coin we could either try to help clients see the other
(brighter) side or examine the ideas standing as alternatives to
individualism (for example, communitarianism). Rather than refram-
ing individualism for clients, we have in our therapeutic work been
exploring ways to counter the shadowy side of the confidential-
individual construct by working to promote a greater sense of
connectedness with others.

In our practice, we integrate principles and values from marriage
and family therapy and social work. We work from a perspective we
call community-minded family therapy (St George and Wulff, 2006;
Wulff and St George, 2007). By the phrase community-minded we
mean that, as we listen to the particular dilemmas our client families
describe, we also are listening for clues in their stories that can help us
understand how the societal grand narratives that are enveloping the
therapeutic system (client and helpers) are at work. It is not just the
family who has become hypnotized or pulled into an invisible but
influential set of ideologies and preferred practices. As they meet,
clients and therapists are operating under the influence of unspoken
and unconsidered dominant ideas that permeate the worlds within
which we live and work. Confidentiality, as constructed and practised,
is an example of one of those ideas and practices derived from the
grand narrative of individualism and independence.

Therefore, when we work from a community-minded family
therapy perspective we are (1) identifying grand narratives that
influence us all, (2) organizing our conversations to include talk about
the ways that grand narratives constrain or slow our thinking, and
then (3) figuring out how we can take steps towards better managing
the taken-for-granted influences in our communities that limit or
hinder families.

As I (SSG) reflect on my hesitation about having Betty and Madeline
meet and wonder what underpinned those feelings, I think I was
concerned that I might be crossing an ethical line in the eyes of my
profession and would be harming my client in doing so. Often when
therapists see a potential ethical problem or breach in our thinking or
behaviour, we become alarmed and consequently wary of the situation
or issue. We often imagine a worst case scenario and find ourselves

208 Daniel Paul Wulff et al.

becoming very cautious and conservative, desirous of steering wide of
any legal scrutiny. In a sense, the situation in question becomes
abstracted into a framework of the legal and ethical versus the illegal
and unethical, and the specific context and circumstances of the
client’s life as a basis for decisions is largely disregarded. The situation
becomes centred on the need for the therapist to be safe and secure
within professional boundaries, irrespective of the consequences for
the client.

Clients often indicate to us that they believe their problems are
unlike those of others and they often feel ashamed and unworthy
because of their perceived weakness or problem. Is a therapist’s
reassurance that they are not alone, not a failure, and not hopeless
robust enough to counteract their sense of isolation? Betty, for
example, was convinced that she would never be seen as a success
as a result of the daily experiences and messages that emphasized her
inability to be a good mother and self-sufficient in the eyes of her
helpers. She told us quite clearly, when we began working with her,
that she ‘needed a village’ more than she needed therapy and
parenting classes. Even though presenting problems differ and the
ways that families live out similar problems differ, we are beginning to
wonder if using the one client to one therapist model may unin-
tentionally contribute to clients’ feelings of isolation. Failing to join
together people who have commonalities in their life situations may
render some possibilities of changing their lives invisible (Madigan
and Epston, 1995). In a study of folk healing traditions around the
world, Keeney (2007) explains that psychotherapy as practiced in the
modern Western world is the youngest healing tradition. He states
that as such it would do well to consider the wisdom of older healing
processes; those that rely heavily on bringing the relevant community
together to deal with problems posed by individuals in that commu-
nity. Confidentiality came along with the professionalization of ther-
apy. The emphases of professional helpers tended to discount what
non-professionals had been doing. Society’s reification of profession-
alism and clinical procedure tends to solidify therapy as the preferred
and superior solution. Individual strength, family involvement and
community support have trouble being recognized as significant
contributors to health and well-being (McKnight, 1995).

In the second illustration, the supportive services that church
members wanted to offer to the families were valuable. But because
they were members of the laity (not professionals), their access to the
client families and any knowledge about them was inconsistent with

Revisiting confidentiality 209

confidentiality standards. Even if one tried to develop formal ways to
authorize such involvement through permission forms or releases,
because the church people were not credentialed practitioners such
authorizations were not possible. Technically, the church community
and our clients should remain separate, especially because the clients’
status as clients would become known to non-professionals. Seeking
client permission for such potential interactions is complicated
because the therapist may be perceived as wielding power over the
client by simply inquiring about this possibility – there may be a
perception that the client could not refuse the offer.

In the third illustration we were not direct participants in the situation
but were aware of the events through the media coverage. Conventional
standards of confidentiality were implemented in the process of hand-
ling each episode of abuse that was reported to the church authorities. It
is our understanding that the details of the abuse were discussed with
the abused individuals and their families as well as with the clergy
accused of the unethical and abusive conduct. For reasons of confidenti-
ality, these episodes were not made public in any way – apparently they
were not even disclosed to legal authorities or ethics boards. Because
this small circle of people kept the information cloistered, the public was
unaware of the risk in their midst. Once the story broke into the media,
questions were asked regarding the responsibility for the consequences
of the subsequent abuses. The church authorities did not acknowledge
the connection between the abuse reports they had dealt with and the
subsequent abuses by the clergy.

Worker isolation

The above practice has also helped us reconsider the impact of this
professionally constructed sense of isolation on both clients and
therapists. Just as clients may feel isolation or aloneness so, too, may
the therapists. They feel the legal jeopardy of failing to adhere to their
professional code of ethics while being disinclined to discuss their
dilemma with other professionals for fear of being judged negatively
for even broaching the issue. An unfortunate by-product of holding
these feelings of isolation is that they often remain hidden and
unspoken. When I (SSG) kept my dilemma to myself, I was extremely
restless and nervous and, unfortunately, isolated. When I did share it
with my colleagues I felt liberated and relieved. Clearly, professional
consultation is crucial in reducing feelings of isolation and worry, and

210 Daniel Paul Wulff et al.

also in providing new perspectives and ideas upon which to build.
Here confidentiality is stretched as a concept.

The situation with the church community was especially poignant.
Their offer to help was heartfelt and it must have been difficult for
them to be told that their offer would be denied. Similarly, the
professionals who were involved with the abusers and the abused
were likely to be frustrated or restricted as much of their work was
circumscribed by fears of legal action.

Teaching confidentiality

Students just becoming acquainted with their professional discipline
may be especially prone to feelings of jeopardy associated with a strict
mandate to adhere to the core principle of confidentiality. Students
are presented with their profession’s specific code of ethics along with
a categorical directive to abide by it – often without question (Reamer,
2001; Vesper and Brock, 1991). Unfortunately, confidentiality has
become enveloped in a legal and political discourse that tends to
stimulate a fearful compliance on the part of helpers to avoid being
sued. Rather than being considered a set of behaviour and protocols
that provide guidance on how to better serve clients, confidentiality is
presented as a legalistic set of proscriptions designed to insulate
helpers from legal consequences. Regrettably, it can lead helpers to
think that being ethical involves only a strict adherence to component
parts of one’s professional code of ethics instead of envisioning ethical
behaviour in the therapeutic relationship as a negotiated interaction
(Swim et al., 2001). In response to this fear of legal sanction, practi-
tioners are advised to maintain a clear and set distance from clients – a
professional boundary that accentuates separateness and isolation.

Purposeful questioning

If we, as family therapists, are prepared to engage in critical reflection
and purposeful questioning of effective family therapy practice that
involves deconstructing confidentiality we must be willing to ask the
following question:

In my work with this family, would it be better to keep this family’s
situation between just them and me or would it be better to include
others?

Revisiting confidentiality 211

This is a crucial question. It opens up the possibility of including more
individuals and networks of support in our efforts to be helpful. In
any family therapy practice there are occasions and opportunities to
work with other professionals and with others who are not profes-
sionals (for example, Big Brothers and Big Sisters, volunteers in
schools or in community centres, extended family members and
neighbours). These persons can be very helpful in the therapeutic
work we do with families. In order to address this question, we will
need to discuss it with the client family. They have a vested interest in
the progress of therapy and should be consulted in key therapeutic
decisions. In fact, this option may not be one they are familiar with
and, given the prevalence of their sense of isolation and worry about
others knowing of their situation, it will be necessary to discuss with
them the possible advantages and disadvantages of this idea. Perhaps
the mere discussion of this might open the client to imagine the idea
of not being isolated. The story of Betty and Madeline demonstrates
the potential of this possibility. When we talk about discussing options
with the family, we include all members – all have a voice. If the family
members disagree with one another we invite them to continue to
discuss the issue and come back with a family decision.

To engage in deliberate conversations with clients regarding con-
fidentiality involves several elements. Firstly, one must believe that the
client has the ability and security to consider this possibility in a
realistic way. If a therapist does not trust the client in this way then any
discussion of this nature could be very difficult. Secondly, the therapist
would need to be willing to entertain all possibilities even-handedly.
The therapist would need to be careful not to over-promote one
choice over another. Thirdly, if the client expressed any doubts or
reservations, the conversation would need to honour those ideas. This
process of negotiating the conditions of therapy would allow clients to
feel respected for their own ideas and create a sense of confidence that
the family can organize and privilege those aspects of therapy they
think are likely to be most beneficial.

Conclusion

We have found the process of revisiting confidentiality to be useful in
freeing our thinking about what we do as therapists. Even important
and cherished notions like confidentiality have a shadowy side that we
must have the courage to reflect upon critically if we take seriously the
challenge to constantly improve our abilities to help client families.

212 Daniel Paul Wulff et al.

Protecting clients from unwanted outside intrusiveness as they
struggle with their life issues is a critical value that we wholeheartedly
support. Exploitation is a real possibility when clients discuss their
lives and vulnerabilities with others. Our discussion here is in no way
an effort to undermine this important consideration. However, we
have also come to understand that in attempting to reduce or
eliminate exploitation confidentiality, practiced as a uniform and
unwavering protocol cannot guarantee protection from exploitation.
In a similar vein, Tomm (1991) has noted that not all aspects of dual
relationships (for example, therapy and supervising) are bad. Indeed,
the potential benefits that would accrue from culturally appropriate,
community-minded, deeply-connected interrelationships are negated
when, as our examples illustrate, clients are denied greater openness
to engage and interact with others and with their professional helper.

In an ever-changing world context, new issues (for example, global
warming, economic crises and international terrorism) constantly
arise that challenge prevailing world-views as well as the current state
of professional wisdom. Our effort to revisit the topic of confidentiality
is only one of a growing number of professional concerns that could
benefit from our critical reflection and deeper questioning. Reamer
(1995) succinctly expresses this sentiment:

The bottom line for us is that social work is by definition a profession
with (a) moral mission, and this obligates its members (to) continually
examine the values and ethical dimensions of practice. Anything less
would deprive social work’s clients and the broader society of (a) truly
professional service. (p. 190)

The innovators and leaders in family therapy have advocated for a
long time, novel and unconventional approaches to working with
clients in order to meet the challenge of helping client families achieve
success and happiness. We believe that such creativity and innovation
are still worthwhile and useful if we are willing to revisit and expand
our core beliefs and traditional practices.

References

Auerswald, E. H. (1981) Interdisciplinary versus ecological approach. In G. D.
Erickson and T. P. Hogan (eds) Family Therapy: An Introduction to Theory and
Technique (2nd edn pp. 404–413). Monterey, CA: Brooks and Cole.

Besthorn, F. (2002) Radical environmentalism and the ecological self: rethinking
the concept of self-identity for social work practice. Journal of Progressive Human
Services, 13: 53–72.

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Clark, C. (2006) Against confidentiality? Privacy, safety and the public good in
professional communications. Journal of Social Work, 6: 117–136.

Haley, J. (1977) Problem-solving Therapy: New Strategies for Effective Family Therapy.
San Francisco, CA: Jossey-Bass.

Keeney, B. (2007) Documentary (Director M. Mascarin) Retrieved 20 April 2008
from http://www.shakingmedicine.com/bradford-keeney/documentary.php

Laye, C. (1994) The Dark Child (Trans. J. Kirkup and E. Jones). New York: Farrar,
Straus and Giroux.

McKnight, J. (1995) The Careless Society: Community and its Counterfeits. New York:
Basic Books.

Madigan, S. and Epston, D. (1995) From ‘Spy-chiatric gaze to communities of
concern: from professional monologue to dialogue. In S. Friedman (ed.) The
Reflecting Team in Action: Collaborative Practice in Family Therapy (pp. 257–276).
New York: The Guilford Press.

Moore-Kirkland, J. and Vice Irey, K. (1981) A reappraisal of confidentiality. Social
Work, 26: 319–322.

Pilisuk, M. and Parks, S. H. (1986) The Healing Web: Social Networks and Human
Survival. Hanover, NH: University Press of New England.

Reamer, F. G. (1995) Social Work Values and Ethics. New York: Columbia University
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Reamer, F. G. (2001) Tangled Relationships: Managing Boundary Issues in the Human
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Smith, P. (2003, April 9) Kelly knew of abuse, kept priest in post. Courier Journal.
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214 Daniel Paul Wulff et al.

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