Anushka Ravishankar
The therapeutic alliance is a crucial component in the therapeutic process and has been extensively documented in research (Leahy, 2008; Marziali & Alexander, 1991; Comas-Díaz, 2006). Several definitions of this construct exist, with all of them being underpinned by the same fundamental principles. The key elements that are more or less universally recognised as encompassing the therapeutic alliance are “the collaborative nature of the relationship, the affective bond between patient and therapist, and agreement on treatment goals and tasks” (Stubbe, 2018 p. 402). Inherent in the process of affective bonding and the development of a sense of collaboration is the building of trust. Trust between the client and therapist is widely accepted as a necessary ingredient for the effectiveness of psychotherapy (McGuire et al., 1985). Crucial in facilitating trust within the therapeutic relationship is confidentiality: “the duty to protect client privacy that comes from the fiduciary nature of the professional relationship. It also is a fundamental standard in the Ethical Principles of Psychologists and Code of Conduct” (Younggren & Harris, 2008).
However, exceptions to the rules of confidentiality exist in situations where the therapist has a larger ethical duty to fulfil before their duty to the client. For instance, when a client threatens to harm an individual, the therapist is required to break confidentiality and alert the authorities (American Psychological Association, 2017). Nevertheless, ethical dilemmas are rarely unambiguous as seen in Episode 8, Season 1 of the American television show Boston Legal, titled ‘Loose Lips’. One of the lawyers at the fictional firm ‘Crane, Poole and Schmidt’ is approached by her therapist for legal advice. One of his clients had threatened to harm his ex-wife during one of their sessions. While the therapist has a duty to maintain what is shared with him confidential, he perceived a very real threat to the client’s ex-wife. Finally, the therapist shares this information with the client’s ex-wife in order to warn her of what he believed to be real danger. When the client learns that his therapist has broken confidentiality, he sets out to his ex-wife’s home to reassure her that he didn’t in fact mean any real harm and that he was simply letting out his frustrations during therapy. In an unexpected turn of events, his ex-wife has armed herself with a gun because she is overcome with paranoia and when the client shows up at her home, she assumes that he means to kill her and shoots him dead (Kelley & Shapiro, 2004).
As illustrated in this TV show, the decision to break confidentiality is a complex one and requires great acumen on the part of the therapist. If the therapist perceives a threat where there is none (as seen in ‘Loose Lips’) or fails to perceive a threat where a legitimate one exists, dire consequences may have to be faced by innocent individuals. While the consequences in reality may not be as dramatic as seen in the TV show, the decisions taken by the therapist when faced with such an ethical dilemma have very real implications for the safety of the involved individuals. Rather than leaving the decision up to the subjective judgement of each therapist, the Ethical Principles of Psychologists and Code of Conduct (American Psychological Association, 2017) requires therapists to report any and all indications of intent to harm to relevant authorities. In this way, no genuine threat goes unaccounted for.
By alerting the appropriate authorities, the therapist can protect against misunderstandings and issues arising from breaking confidentiality when no real threat exists on the part of the client. Furthermore, the appropriate authorities are aware of the procedures required to protect against and diffuse the situation. This would bring about some control as opposed to if the therapist informs the individual in question themselves. However, the very act of breaking confidentiality, real threat or not, causes a significant rupture in the client-therapist relationship and induces feelings of betrayal, hurt, confusion and anger in the client (Bean et al., 2011). Steinberg et al. (1997), found that 27% of clients and their family drop out of therapy following a breach in confidentiality, suggesting that sometimes the rupture is too deep to mend. Nonetheless, the remaining 73% of cases suggest that there are ways in which to work through the break and the feelings of rejection and abandonment in the client. In the event that the relationship cannot be mended in a therapeutic manner, the therapist may have to refer the client to another professional so that they may continue their therapeutic work elsewhere.
Ultimately, the therapist has a responsibility to uphold their duties to the law, but also take extra care to guide the client through the process of breaching confidentiality and the intense emotions that follow. Otherwise, the rupture in the relationship with the therapist may end up becoming a traumatic experience in itself that transfers to future relationships and therapeutic settings. In summary, such ethical dilemmas can be complicated and demanding for the therapist and they must make full use of the resources and avenues of support available to them in order to navigate the situation as best as possible.
References
American Psychological Association (2017). Ethical Principles of Psychologists and Code of Conduct.
Bean, H., Softas-Nall, L., & Mahoney, M. (2011). Reflections on mandated reporting and challenges in the therapeutic relationship: A case study with systemic implications. The Family Journal, 19(3), 286–290. https://doi.org/10.1177/1066480711407444
Comas-Díaz, L. (2006). Cultural variation in the therapeutic relationship. Evidence-Based Psychotherapy: Where Practice and Research Meet., 81–105. https://doi.org/10.1037/11423-004
Kelley, D. E. (Writer & Director), & Shapiro, J. (Writer). (2004, November 28). Loose Lips (Season 1, Episode 8) [TV Series Episode]. In D.E. Kelley & B. D’Elia (Executive Producers), Boston Legal. David E. Kelley Productions; 20th Century Fox Television.
Leahy, R. L. (2008). The therapeutic relationship in cognitive-behavioural therapy. Behavioural and Cognitive Psychotherapy, 36(6), 769–777. https://doi.org/10.1017/s1352465808004852
Marziali, E., & Alexander, L. (1991). The power of the therapeutic relationship. American Journal of Orthopsychiatry, 61(3), 383–391. https://doi.org/10.1037/h0079268
McGuire, J. M., Toal, P., & Blau, B. (1985). The adult client's conception of confidentiality in the therapeutic relationship. Professional Psychology: Research and Practice, 16(3), 375–384. https://doi.org/10.1037/0735-7028.16.3.375
Steinberg, K. L., Levine, M., & Doueck, H. J. (1997). Effects of legally mandated child-abuse reports on the therapeutic relationship: A survey of psychotherapists. American Journal of Orthopsychiatry, 67, 112-122. https://doi.org/10.1177/1066480711407444
Stubbe, D. E. (2018). The Therapeutic Alliance: The fundamental element of psychotherapy. FOCUS, 16(4), 402–403. https://doi.org/10.1176/appi.focus.20180022
Younggren, J. N., & Harris, E. A. (2008). Can you keep a secret? confidentiality in psychotherapy. Journal of Clinical Psychology, 64(5), 589–600. https://doi.org/10.1002/jclp.20480
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