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Section 29
Therapist Boundaries

Question 29 | Test | Table of Contents

Duty to Report Abuse vs. Duty of Confidentiality

The following case study is meant as a review of the key issues regarding confidentiality and brings up questions that may be used as teaching tools in your supervisory sessions.

"The Case of the Homosexual Husband"
David, the oldest of three children, was a son of a well-to-do manufacturer. David's father valued physical prowess and athletic accomplishments, areas in which the boy showed little interest. When David was twelve or thirteen years old, conflicts with his father resulted in almost nightly arguments. It was evident that David's father had become concerned about his son's mannerisms and considered them to be unmanly.

David's school work deteriorated considerably, and he became withdrawn. His father decided to send him to military school, but he remained there only six months. By this time, David had told his parents that he was a homosexual, and that he had engaged in and was engaging in homosexual practices. He came home and completed his high school studies, but he did not go to college and continued to live at home.

Five years later, a woman named Allison visited her family physician for a premarital exam. The physician was the same practitioner who had treated David several years earlier. Allison was twenty-four years old and had been under the physician’s care since the age of fourteen. A close and warm relationship had developed between the physician and Joan's family, so it was normal for him to ask about her fiancé. When he did, he learned that she was about to marry David. She had known him only briefly, but well enough, she felt, to be certain about her choice. Nothing more was said at the time.

David and Allison were married shortly thereafter and lived together for six months. The marriage was then annulled on the basis of nonconsummation. David told Allison that he was homosexually oriented, and she learned as well that not only did they share the same physician, but also the physician had been aware of David's homosexuality. She subsequently suffered from depression as a result of this experience and was angry that her physician had remained silent about David. She felt that she could have been spared this horrible episode in her life - that it was his duty to inform her. His failure to do so was an act of negligence resulting in deep emotional trauma.

To whom did the physician owe primary allegiance? Do the interests of one patient prevail over the requirements of confidentiality surrounding another's case?

In uncomplicated cases, the practitioner may convey to the patient any medically relevant information that would be potentially meaningful or useful in medical decision making. The physician's Hippocratic ethic instructs him to do what he thinks will benefit his patient.

However, the tradition of physician ethics on confidentiality is not at all clear. The Hippocratic Oath is ambiguous, as it states that the physician should keep secret things he learns in his practice that ought not to be "spread abroad". Which things those are is not specified. The World Medical Association's (WMA) version of the Hippocratic Oath states simplistically that the physician will keep confidences entrusted in him.

On the other hand, the version by the American Medical Association takes a quite different approach. Its principle of ethics says that the physician ought not to disclose things learned in confidence except in three cases: when disclosure is required by law, when it is in the patient's interest, or when it is in the interests of other people.

Sounds similar to the therapist’s Code doesn't it?

The AMA indicated the physician's duty to disclose to persons other than the patient from whom the relevant information has been learned, thus taking a much more social course. But it opens the door for a wide range of disclosures.

No where does the traditional physician's ethics say anything about resolving conflicts between duties to two patients whose interests may conflict and may differ from the practitioner's.

Duty to Report Abuse vs. Duty of Confidentiality
Next let’s examine just such a case: "When a Doctor's Duty to Report Abuse Conflicts with a Duty of Confidentiality to the Victim", by T.J. David.

Fifteen years after she has been admitted to hospital with unexplained bruising, a woman asks to see her pediatric medical records. Professor T. J. David describes the dilemma surrounding the women's allegations of sexual abuse.

Here's a case where a Doctor's Duty to Report Abuse conflicts with the Duty of Confidentiality to the Victim.

A 21 year old woman asked to see her medical records from a children's hospital. The pediatrician in charge of her case was approached by the hospital administration.

The case was one of possible non-accidental injury. Because of the risk of misunderstanding what had been written in the notes, not to mention their poor legibility, the pediatrician met the woman and went through the medical records with her. He also gave her a full photocopied set to keep. The woman had been a patient 15 years before. At the age of 6 she had been admitted to the hospital for a few days' observation, because she had a large number of bruises for which there was no adequate explanation. Screening tests gave no evidence of a coagulation disorder and a skeletal survey showed no fractures.

Careful inquiries were made of social services, the Child Abuse Agency, the health visitor, the child's general practitioner, and her school. All reports were favorable. The girl came from a good family, there were no concerns, and there was nothing in her background to suggest that this was a case of non-accidental injury.

As a result, social services decided not to hold a case conference and the child was discharged. The pediatrician notified all the above agencies about the bruising, and it was suggested that any further episodes of bruising should be reported immediately to social services. The child was never seen again with injuries.

When the pediatrician saw the 21 year old woman, he had no idea why she wanted to look at her records. He was concerned that the family might have been disrupted because of the earlier inquiries into possible child abuse or that the hospital had failed to detect abuse and she had been injured further.

After the pediatrician had gone through her hospital notes, the woman explained that the bruises had been inflicted deliberately, and that she had wanted to see from her medical notes if we had known about the sexual abuse that she had experienced. She had been sexually abused by a male baby-sitter over a period of weeks, and had been beaten up by this man whenever she had shown an unwillingness to cooperate. He had threatened to harm her if she ever reported him; she did not report him.

The woman said that this man still lived in the same neighborhood and now had a young daughter of his own. The pediatrician and women discussed at length what action she might take. She was unwilling to report the matter to the police or social services, and she repeatedly said that I should not under any circumstances share this information with anyone else. She told the pediatrician that she had had bulimia for some years. This she attributed to her childhood experiences, and she feared that bringing the subject out into the open now would make her distressed and depressed.

The woman's request to maintain confidentiality placed the pediatrician in a difficult position. Her story, if true, suggested that other children might have been harmed or might still be at risk, and he saw little reason to doubt her. The question was whether the pediatrician had a duty to report the matter that outweighed respect for the woman's rights for confidentiality.

What do you think would be the right thing to do in this situation? There is, of course, more than one possible answer.

Use of a Case Study to Teach a Thought Process
I use the following case study and multiple choice answers to facilitate a supervisee’s thought process.

Linda, a battered woman, informs you (the supervisee) that her husband has threatened to kill her. He owns a gun. She has been unable to sleep soundly and has developed generalized anxiety. She is afraid that if her husband finds out that she has told you about his abuse, that he will follow through on his threat. You should...
a. urge your client to leave her husband and move to a shelter for battered women
b. work with the client to document the frequency, magnitude and duration of her reactions to the husband's threats
c. inform your client of her options
d. interview the husband in order to help him avert behaving in a way that will cause problems for both his wife and himself

The correct answer is C. The client has the right to have this information kept confidential. C states "inform your client of her options".

Peer-Reviewed Journal Article References:

Chenneville, T., & Gabbidon, K. (2020). HIV, confidentiality, and duty to protect: Considerations for psychotherapists in the age of treatment as prevention. Psychotherapy, 57(1), 7–14.

Goto, A., Iwakabe, S., & Heim, N. (2021). Therapeutic courage in novice therapists in Japan: A qualitative study. Journal of Psychotherapy Integration.

Wu, K. S., & Sonne, J. L. (2021). Therapist boundary crossings in the digital age: Psychologists’ practice frequencies and perceptions of ethicality. Professional Psychology: Research and Practice, 52(5), 419–428.

Linda, a battered woman, informs you that her husband has threatened to kill her. He owns a gun. She has been unable to sleep soundly and has developed generalized anxiety. She is afraid that if her husband finds out that she has told you about his abuse, that he will follow through on his threat. You should... To select and enter your answer go to Test.

Section 30
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