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Running head: FARMERS IN EUROPE BEFORE 5000 YEARS
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FARMERS IN EUROPE BEFORE 5000 YEARS AGO
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The inhabitants of Europe lived in ancient times on fishing and
hunting animals. In the Neolithic era, they raised animals and
they worked in the agriculture field. Thus human appeared in
Europe in the late Stone Age. They were hunters and collectors
of food and tools. They left traces of 25,000 to 10,000 years old
in about 200 caves around Europe, mostly in Spain and France.
In the Neolithic period, Europe began to practice agriculture to
replace it with hunting. During the sixth millennium BC,
agriculture has spread widely in Europe and it becomes the main
work or job of the people from that time until the modern era.
In this paper, I will focus on people in Europe before 5000 BC.
I will focus on how the people were in the past and how they
managed to live in the circumstances of the great changes that
took place during that period. How was their lifestyle at that
time as farmers or people who lived nearby farms, and how that
affects their lives?
In the past people who were in Europe survived the changes by
adopting Agriculture, basically they started breeding of animals
and cultivation of land plants, the reason as to why they opted
to engage in agriculture is because they were interested in
providing food for their own use, good sources of fiber, the
were also interests in producing plants which they could use for
medicinal purposes. Examples of plants which were used for
medicinal purposes comprised of basil, chamomile and
Echinacea. The other products which were produced were just
meant to sustain as well as enhance life (Lohrberg, 2016).
Agriculture played a major role in the development which
resulted to the rise of sedentary human civilization, this
happened because production of domesticated species which
were purposely meant to create food surpluses which mainly
enabled people to live in various cities in Europe. In the era
when people stopped hunting and started farming, they gathered
wild grains began to plant them, before they became
domesticated. After hunting came to en end people started
rearing domestic animals which comprised of; sheep, cattle and
Pigs, most of the crops originated from at least twelve regions
of the world. In this era Industrial agriculture was mainly based
on large-scale monoculture and it later dominated agricultural
output, this still happens regardless of the fact the most people
across the world still depend on subsistence agriculture
(Lohrberg, 2016).
Adoption of agriculture played a major in the lives of the people
of Europe. First it led to production of enough food which could
be used by people who were living in the rural and urban areas.
It took a short time and the farmers started producing food
products in large quantities, this was very crucial as it helped in
provision of food for most of the people in Europe. Agriculture
became the main source of livelihood for most of the people in
Europe. There are several reasons as to why people opted to go
for agriculture, I will briefly describe the reasons as to why
people had to stop hunting and opt for agriculture. Various
researches show that approximately 80 % of the people who
lived in that era directly relied on agriculture as a source of
living. The reason as to why dependence on agriculture was so
high was as a result of due to none development of non-
agricultural activities which were capable of absorbing the
population which had started to grow at very fast rate (Knudsen,
2012).
The second reason as to why people started producing
agricultural products is because they were interested in
producing fodder for their livestock, this was as result of
conversion most of the land into production of crops hence
making it hard to produce enough food stuffs for their animals.
Agricultural activities helped in provision of fodder for
domestic animals. The domestic animals which were reared for
instance, Cows provided the farmers with milk and meat. Most
of the livestock which were reared helped the farmers meet the
food requirements. Another reason as to why people opted to
go for agriculture is because the farmers were interested in
production of raw materials, agriculture became the main source
of main source of raw materials to most of the industries. For
instance agriculture led to production of jute fabric and cotton
which were raw material for most of the industries. Agricultural
activities also led to production of sugar and tobacco which
were raw material for some of the industries.
Agriculture also led to production of non-edible and edible oils
also which were raw material for some industries. In addition,
to this many more industries, for instance the processing of
fruits and rice husking and vegetables rice relied on raw
material mainly from agriculture. The last reason as to why
people opted to go for agriculture and abandon hunting is
because agriculture provided employment opportunities to most
of the people as compared to hunting, people who had large
tracts of land hired people to work on their farms, this helped in
provision creation of employment to most of the people and
that’s why people had to stop hunting and start farming
(Neumeister, 2004).
After this change people realized that there was need to have
food security, this was as a result of the fact that hunting was
no longer practiced and it could not provide enough for the
population. Having the need to ensure that there is food
security, people had to adapt agriculture, a stable agricultural
sector was very vital to ensure that the nation and enough food
security. The main necessity of any nation is food security.
Food security helps in prevention of malnourishment which is
one of the main problems. Reliance on agricultural products is
usually associated industries for their main source of income
(Neumeister, 2004).
In that era, there was need to have an economic development
hence people had change from hunting to agriculture. Bearing
the fact that agriculture provides employment for many people
it greatly contributes to development of the economy of a nation
and that’s why Europe had to go for agriculture rather than
hunting. There was need to have a national income level and the
people’s standard of living improved, therefore there was need
to adapt agriculture. The increased rate of development in the
agricultural sector provided increased motivation for
development and progressive outlook. Adaption of agriculture
helped to create good atmosphere for the overall economic
development of Europe.
There are several reasons as to why agriculture was successful
in Europe, first availability of land played a major role in the
success of agriculture in Europe. The second reason as to why
agriculture was successful is because of availability of labor
force, people were willing to work in the farms and hence it
became easy to for agriculture to be carried out. The success of
agriculture in Europe is also attributed to availability of tools
and fertilizers and some chemicals which were used to control
pests. The major agricultural products which were produced in
Europe were grouped into various categories comprising of;
fibers, foods and raw materials. The classes of foods produced
comprised of fruits, vegetables, oils, fuels and fibers (Sanders,
2015).
There are several forms of agriculture which were practiced in
Europe. The first form of agriculture which was practiced was
mixed farming which mainly entailed agricultural production of
crops and livestock in the same farm. This form of agriculture
was mainly practiced in the areas which had fertile soils and
areas which had rough terrain. Another form of farming which
actually originated from Europe and was practiced in this era is
dairy farming, this form of farming was successful due to
temperate climate and close proximity to the market (Sanders,
2015).
Agriculture had a great impact on the people who lived near the
farms. It led to improvement in the living standards of the
people, this is because it led to creation of job opportunities,
with employment people were able to get food and also cater for
the other need and hence this led to an improvement of their
living standards. Another impact of the people who lived near
the farms is that they were able to get enough food to support
their families and hence developing in financial as well the
economic aspect.
References
Knudsen, I. H. (2012). New Lithuania in Old Hands: Effects and
Outcomes of EUropeanization in Rural Lithuania. London:
Anthem Press.
Lohrberg, F. (2016). Urban Agriculture Europe. Jovis.
Neumeister, L. (2004). Moving Towards Pesticide Reduction: ...
Realising Best Agricultural Practice in Central and Eastern
Europe. Pestizid-Aktions-Netzwerk e.V.
Sanders, I. (2015). Collectivization of Agriculture in Eastern
Europe.
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:
[email protected]
uc.edu).
Journal of Human Behavior in the Social Environment, Vol.
13(4) 2006
Available online at http://www.haworthpress.com/web/JHBSE
© 2006 by The Haworth Press, Inc. All rights reserved.
doi:10.1300/J137v13n04_04 55
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:
<[email protected]
haworthpress.com> Website: <http://www.HaworthPress.com>
© 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
http://www.HaworthPress.com
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
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
13
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
14
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.
REFERENCES
Barker, R.L. (2003). The social work dictionary (5th ed.).
Washington, DC: NASW
Press.
Barker, R.L. (1999). The social work dictionary (4th ed.).
Washington, DC: NASW
Press.
Behnke, S. H., Winick, J.D., & Perez, J. D. (2000). The
essentials of Florida mental
health law: A straightforward guide for clinicians of all
disciplines. New York: W.W.
Norton.
Saxon, Jacinto, and Dziegielewski 71
Berliner, A. K. (1989). Misconduct in social work practice.
Social Work, 34, 69-72.
Boynton v. Burglass, 590 So. 2d446 (Fla. App. 3 Dist. 1991).
Corey, G., Corey, M.S., & Callanan, P. (1998). Issues and
ethics in the helping profes-
sions. Pacific Grove, CA: Brooks Cole.
Dickson, D. T. (1998). Confidentiality and privacy in social
work: A guide to the law for
practitioners and students. New York: Free Press.
Dolgoff, R., & Skolnik, L. (1996). Ethical decision making in
social work with groups:
An empirical study. Social Work with Groups, 19(2), 49-63.
Dunlap, K. M., & Strom-Gottfried, K. (1998). Maintaining the
confidence in confiden-
tiality. The New Social Worker, 5(3), 10-11.
Dziegielewski, S.F. (2004). The changing face of health care
social work: Professional
practice in the managed behavioral health care (2nd edition).
New York: Springer.
Dziegielewski, S.F. (2002). DSM-IV-TR™ in action. New York:
Wiley and Sons.
Edward, J. (1999). Is managed mental health treatment
psychotherapy? Clinical Social
Work Journal, 27, 87-102.
Gothard, S. (1995). Legal issues: Confidentiality and privileged
communication. Ency-
clopedia of Social Work (Vol. 2, pp. 1579-1584). Washington,
DC: NASW Press.
Green v. Ross, 691 So. 2d 542 (Fla. App. 2 Dist. 1997).
Holland, T. P., & Kilpatrick, A. C. (1991). Ethical issues in
social work: Toward a
grounded theory of professional ethics. Social Work, 36(2),
138-145.
Kirst-Ashman, K. K., & Hull, G., Jr. (1993). Understanding
generalist practice. Chi-
cago: Nelson-Hall Publishers.
Kopels, S., & Kogle, J. D. (1994). Teaching confidentiality
breaches as a form of dis-
crimination. Arete, 19(1), 1-9.
Levy, C. S. (1993). Social work ethics on the line. New York:
The Haworth Press, Inc.
Loewenberg, F. M., & Dolgoff, R. (1996). Ethical decisions for
social work practice.
Itasca, IL: F. E. Peacock Publishers.
Loewenberg, F.M., Dolgoff, R., & Harrington, D. (2000).
Ethical decisions for social
work practice (sixth edition). Itasca, IL: F.E. Peacock
Publishers.
National Association of Social Workers. (1996). Code of ethics.
Silver Spring, MD:
Authors.
Reamer, F. G. (1995). Social work values and ethics. New York:
Columbia University
Press.
Reamer, F. G. (1998) The evolution of social work ethics.
Social Work, 43, (6),
488-500.
Santa Cruz v. N. W. Dade Community Health Center 590 So. 2d
444 (Fla. App. 3 Dist.
1991).
Strom-Gottfried, K., & Dunlap, K. M. (1999). Unraveling
ethical dilemmas. The New
Social Worker, 6(2), 8-12.
Strom-Gottfried, Kimberly, J., & Corcoran, K. (1998).
Confronting ethical dilemmas
in managed care: Guidelines for students and faculty. Journal of
Social Work Edu-
cation, 34(1), 109-119.
Tarasoff v. Regents of the University of California, 551 p. 2d
344 (1976).
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:
[email protected]
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:[email protected]
mailto:[email protected]
mailto:[email protected]
mailto:[email protected]
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.
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.
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
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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
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Street, Malden, MA 02148, USA.
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
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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
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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
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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
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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
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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
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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
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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
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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?
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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.
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.
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.
Revisiting confidentiality 213
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.
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
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Running head FARMERS IN EUROPE BEFORE 5000 YEARS AGO.docx

  • 1. Running head: FARMERS IN EUROPE BEFORE 5000 YEARS AGO FARMERS IN EUROPE BEFORE 5000 YEARS AGO Institutional affiliation Student name Date The inhabitants of Europe lived in ancient times on fishing and hunting animals. In the Neolithic era, they raised animals and they worked in the agriculture field. Thus human appeared in Europe in the late Stone Age. They were hunters and collectors of food and tools. They left traces of 25,000 to 10,000 years old in about 200 caves around Europe, mostly in Spain and France. In the Neolithic period, Europe began to practice agriculture to replace it with hunting. During the sixth millennium BC, agriculture has spread widely in Europe and it becomes the main work or job of the people from that time until the modern era. In this paper, I will focus on people in Europe before 5000 BC. I will focus on how the people were in the past and how they managed to live in the circumstances of the great changes that took place during that period. How was their lifestyle at that time as farmers or people who lived nearby farms, and how that
  • 2. affects their lives? In the past people who were in Europe survived the changes by adopting Agriculture, basically they started breeding of animals and cultivation of land plants, the reason as to why they opted to engage in agriculture is because they were interested in providing food for their own use, good sources of fiber, the were also interests in producing plants which they could use for medicinal purposes. Examples of plants which were used for medicinal purposes comprised of basil, chamomile and Echinacea. The other products which were produced were just meant to sustain as well as enhance life (Lohrberg, 2016). Agriculture played a major role in the development which resulted to the rise of sedentary human civilization, this happened because production of domesticated species which were purposely meant to create food surpluses which mainly enabled people to live in various cities in Europe. In the era when people stopped hunting and started farming, they gathered wild grains began to plant them, before they became domesticated. After hunting came to en end people started rearing domestic animals which comprised of; sheep, cattle and Pigs, most of the crops originated from at least twelve regions of the world. In this era Industrial agriculture was mainly based on large-scale monoculture and it later dominated agricultural output, this still happens regardless of the fact the most people across the world still depend on subsistence agriculture (Lohrberg, 2016). Adoption of agriculture played a major in the lives of the people of Europe. First it led to production of enough food which could be used by people who were living in the rural and urban areas. It took a short time and the farmers started producing food products in large quantities, this was very crucial as it helped in provision of food for most of the people in Europe. Agriculture became the main source of livelihood for most of the people in Europe. There are several reasons as to why people opted to go for agriculture, I will briefly describe the reasons as to why people had to stop hunting and opt for agriculture. Various
  • 3. researches show that approximately 80 % of the people who lived in that era directly relied on agriculture as a source of living. The reason as to why dependence on agriculture was so high was as a result of due to none development of non- agricultural activities which were capable of absorbing the population which had started to grow at very fast rate (Knudsen, 2012). The second reason as to why people started producing agricultural products is because they were interested in producing fodder for their livestock, this was as result of conversion most of the land into production of crops hence making it hard to produce enough food stuffs for their animals. Agricultural activities helped in provision of fodder for domestic animals. The domestic animals which were reared for instance, Cows provided the farmers with milk and meat. Most of the livestock which were reared helped the farmers meet the food requirements. Another reason as to why people opted to go for agriculture is because the farmers were interested in production of raw materials, agriculture became the main source of main source of raw materials to most of the industries. For instance agriculture led to production of jute fabric and cotton which were raw material for most of the industries. Agricultural activities also led to production of sugar and tobacco which were raw material for some of the industries. Agriculture also led to production of non-edible and edible oils also which were raw material for some industries. In addition, to this many more industries, for instance the processing of fruits and rice husking and vegetables rice relied on raw material mainly from agriculture. The last reason as to why people opted to go for agriculture and abandon hunting is because agriculture provided employment opportunities to most of the people as compared to hunting, people who had large tracts of land hired people to work on their farms, this helped in provision creation of employment to most of the people and that’s why people had to stop hunting and start farming (Neumeister, 2004).
  • 4. After this change people realized that there was need to have food security, this was as a result of the fact that hunting was no longer practiced and it could not provide enough for the population. Having the need to ensure that there is food security, people had to adapt agriculture, a stable agricultural sector was very vital to ensure that the nation and enough food security. The main necessity of any nation is food security. Food security helps in prevention of malnourishment which is one of the main problems. Reliance on agricultural products is usually associated industries for their main source of income (Neumeister, 2004). In that era, there was need to have an economic development hence people had change from hunting to agriculture. Bearing the fact that agriculture provides employment for many people it greatly contributes to development of the economy of a nation and that’s why Europe had to go for agriculture rather than hunting. There was need to have a national income level and the people’s standard of living improved, therefore there was need to adapt agriculture. The increased rate of development in the agricultural sector provided increased motivation for development and progressive outlook. Adaption of agriculture helped to create good atmosphere for the overall economic development of Europe. There are several reasons as to why agriculture was successful in Europe, first availability of land played a major role in the success of agriculture in Europe. The second reason as to why agriculture was successful is because of availability of labor force, people were willing to work in the farms and hence it became easy to for agriculture to be carried out. The success of agriculture in Europe is also attributed to availability of tools and fertilizers and some chemicals which were used to control pests. The major agricultural products which were produced in Europe were grouped into various categories comprising of; fibers, foods and raw materials. The classes of foods produced comprised of fruits, vegetables, oils, fuels and fibers (Sanders, 2015).
  • 5. There are several forms of agriculture which were practiced in Europe. The first form of agriculture which was practiced was mixed farming which mainly entailed agricultural production of crops and livestock in the same farm. This form of agriculture was mainly practiced in the areas which had fertile soils and areas which had rough terrain. Another form of farming which actually originated from Europe and was practiced in this era is dairy farming, this form of farming was successful due to temperate climate and close proximity to the market (Sanders, 2015). Agriculture had a great impact on the people who lived near the farms. It led to improvement in the living standards of the people, this is because it led to creation of job opportunities, with employment people were able to get food and also cater for the other need and hence this led to an improvement of their living standards. Another impact of the people who lived near the farms is that they were able to get enough food to support their families and hence developing in financial as well the economic aspect. References Knudsen, I. H. (2012). New Lithuania in Old Hands: Effects and Outcomes of EUropeanization in Rural Lithuania. London: Anthem Press. Lohrberg, F. (2016). Urban Agriculture Europe. Jovis. Neumeister, L. (2004). Moving Towards Pesticide Reduction: ... Realising Best Agricultural Practice in Central and Eastern Europe. Pestizid-Aktions-Netzwerk e.V. Sanders, I. (2015). Collectivization of Agriculture in Eastern Europe. Self-Determination and Confidentiality:
  • 6. 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
  • 7. 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: [email protected] uc.edu). Journal of Human Behavior in the Social Environment, Vol. 13(4) 2006 Available online at http://www.haworthpress.com/web/JHBSE © 2006 by The Haworth Press, Inc. All rights reserved. doi:10.1300/J137v13n04_04 55 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-
  • 8. 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: <[email protected] haworthpress.com> Website: <http://www.HaworthPress.com> © 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
  • 9. 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
  • 10. http://www.HaworthPress.com 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-
  • 11. 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] . .
  • 12. . 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-
  • 13. 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
  • 14. 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
  • 15. 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
  • 16. 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
  • 17. 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%)
  • 18. 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
  • 19. 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
  • 20. 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
  • 21. 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
  • 22. 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
  • 23. 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%
  • 24. 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
  • 25. 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 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 13
  • 26. 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 14 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
  • 27. 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
  • 28. 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
  • 29. 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.
  • 30. 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.
  • 31. 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
  • 32. 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-
  • 33. 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.
  • 34. 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
  • 35. 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
  • 36. 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-
  • 37. 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-
  • 38. 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-
  • 39. 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.
  • 40. 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
  • 41. 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.
  • 42. 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
  • 43. 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,
  • 44. 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
  • 45. 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. REFERENCES Barker, R.L. (2003). The social work dictionary (5th ed.). Washington, DC: NASW Press. Barker, R.L. (1999). The social work dictionary (4th ed.). Washington, DC: NASW Press. Behnke, S. H., Winick, J.D., & Perez, J. D. (2000). The essentials of Florida mental health law: A straightforward guide for clinicians of all disciplines. New York: W.W. Norton. Saxon, Jacinto, and Dziegielewski 71
  • 46. Berliner, A. K. (1989). Misconduct in social work practice. Social Work, 34, 69-72. Boynton v. Burglass, 590 So. 2d446 (Fla. App. 3 Dist. 1991). Corey, G., Corey, M.S., & Callanan, P. (1998). Issues and ethics in the helping profes- sions. Pacific Grove, CA: Brooks Cole. Dickson, D. T. (1998). Confidentiality and privacy in social work: A guide to the law for practitioners and students. New York: Free Press. Dolgoff, R., & Skolnik, L. (1996). Ethical decision making in social work with groups: An empirical study. Social Work with Groups, 19(2), 49-63. Dunlap, K. M., & Strom-Gottfried, K. (1998). Maintaining the confidence in confiden- tiality. The New Social Worker, 5(3), 10-11. Dziegielewski, S.F. (2004). The changing face of health care social work: Professional practice in the managed behavioral health care (2nd edition). New York: Springer. Dziegielewski, S.F. (2002). DSM-IV-TR™ in action. New York: Wiley and Sons. Edward, J. (1999). Is managed mental health treatment psychotherapy? Clinical Social Work Journal, 27, 87-102. Gothard, S. (1995). Legal issues: Confidentiality and privileged communication. Ency- clopedia of Social Work (Vol. 2, pp. 1579-1584). Washington,
  • 47. DC: NASW Press. Green v. Ross, 691 So. 2d 542 (Fla. App. 2 Dist. 1997). Holland, T. P., & Kilpatrick, A. C. (1991). Ethical issues in social work: Toward a grounded theory of professional ethics. Social Work, 36(2), 138-145. Kirst-Ashman, K. K., & Hull, G., Jr. (1993). Understanding generalist practice. Chi- cago: Nelson-Hall Publishers. Kopels, S., & Kogle, J. D. (1994). Teaching confidentiality breaches as a form of dis- crimination. Arete, 19(1), 1-9. Levy, C. S. (1993). Social work ethics on the line. New York: The Haworth Press, Inc. Loewenberg, F. M., & Dolgoff, R. (1996). Ethical decisions for social work practice. Itasca, IL: F. E. Peacock Publishers. Loewenberg, F.M., Dolgoff, R., & Harrington, D. (2000). Ethical decisions for social work practice (sixth edition). Itasca, IL: F.E. Peacock Publishers. National Association of Social Workers. (1996). Code of ethics. Silver Spring, MD: Authors. Reamer, F. G. (1995). Social work values and ethics. New York: Columbia University Press. Reamer, F. G. (1998) The evolution of social work ethics. Social Work, 43, (6),
  • 48. 488-500. Santa Cruz v. N. W. Dade Community Health Center 590 So. 2d 444 (Fla. App. 3 Dist. 1991). Strom-Gottfried, K., & Dunlap, K. M. (1999). Unraveling ethical dilemmas. The New Social Worker, 6(2), 8-12. Strom-Gottfried, Kimberly, J., & Corcoran, K. (1998). Confronting ethical dilemmas in managed care: Guidelines for students and faculty. Journal of Social Work Edu- cation, 34(1), 109-119. Tarasoff v. Regents of the University of California, 551 p. 2d 344 (1976). 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
  • 49. 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
  • 50. 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: [email protected] 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
  • 51. mailto:[email protected] mailto:[email protected] mailto:[email protected] mailto:[email protected] 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
  • 52. 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
  • 53. 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. 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. 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
  • 54. 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
  • 55. 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 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. understood to be afforded only by a professional therapist. This situation is not uncommon in family therapy practice, despite
  • 56. 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
  • 57. 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. 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.
  • 58. 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.
  • 59. 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
  • 60. 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 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. 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
  • 61. 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
  • 62. 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. 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. 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
  • 63. 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
  • 64. 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 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.
  • 65. 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
  • 66. 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
  • 67. we 206 Daniel Paul Wulff et al. 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. 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
  • 68. 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
  • 69. 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 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. 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
  • 70. 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
  • 71. 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.
  • 72. 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. 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,
  • 73. 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).
  • 74. 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 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. 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
  • 75. 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
  • 76. 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. 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. 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
  • 77. 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
  • 78. 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 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.
  • 79. 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
  • 80. 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
  • 81. 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. 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. 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
  • 82. 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
  • 83. 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. Revisiting confidentiality 213 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. Clark, C. (2006) Against confidentiality? Privacy, safety and the public good in professional communications. Journal of Social Work, 6: 117–
  • 84. 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