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Privacy and Confidentiality in the Therapeutic Relationship

Section 5

Question 5 | Test | Table of Contents

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I feel the best answer is D, ask the child in private how the cut and bruise happened.

Now, the reason I feel D is the best answer is because I feel, if confronted, Helen (the mother) may feel pressured to lie about the injury if, in fact, abuse is involved. The best situation is to ask the child when Helen is not present. If that was not a choice, it would be better to either extend the session and discuss it or consider making it an agenda item at the next meeting or try to contact Jodie, setting up a meeting without the mother.

Dr. R Slovenko in his book Psychotherapy, Confidentiality and Privileged Communication writes... Child therapy can never be a strictly two-person arrangement. This is strikingly noted in Freud's treatment of little Hans. It was the father, not Freud, who actually carried out the analysis. Freud himself had only one interview with the boy, but he had frequent consultations with the father. (Freud for some years previously had known the parents; he had treated the wife before she was married, and the husband had attended his lectures.)

♦ Environmental Manipulation Treatment Approach
"Environmental manipulation" as it is called, may be essential in the treatment of children. With some children, it is particularly desirable to involve the child's parents in the treatment process. As is well known, therapeutic gains with the child will often be short-lived unless the parents are also able to change. A meaningful relationship with the therapist often depends upon cooperation. The therapists may find sensitive teachers who may be able, in consultation, to contribute effectively to the child's treatment through the teacher-pupil relationship.

This broad treatment approach, however, as you know, raises some confidentiality issues. The therapist, as a matter of good practice, makes clear to both the child (if he is old enough) and his parents the type of rapport he will have with each. Confidentiality, viewed realistically, is maintained. There is no publication to the world. The psychiatrist in this situation is working with persons who are directly responsible for the patient and who can assist in the treatment. Parents, after all, are legally responsible for their children.

Slovenko writes...There are times, however, when it may be necessary to dismiss the parents and to rely on others. The parents may be psychotic or otherwise disturbed. All physicians have encountered parents who deny treatment to an acutely ill child or who are devastating to the child.

♦ Battered-Child Syndrome
The highly publicized "battered-child syndrome" has resulted in the passage of laws requiring that physicians and hospitals report cases of child abuse observed in the course of their professional practice. Physical assaults on children reportedly may be "a more frequent cause of death than such well-recognized and thoroughly studied diseases as leukemia, cystic fibrosis and muscular dystrophy, and it may rank with automobile accidents."

Many physicians have expressed the view that such laws would be useless without a clause protecting them from retaliation by irate parents who are investigated. Hence, the laws that have been enacted contain provisions protecting those reporting against any civil liability that might arise out of compliance with the statutory requirement. By involving children, parents, and the legal system, the question becomes where do you draw the line of confidentiality and to whom?

Laws make it mandatory for physicians and institutions to report physical abuse of children to the appropriate authority.

♦ Mental Abuse
The area of "mental abuse," which may be much more devastating to the child, is harder to enforce. The percentage of such cases, serious in nature, can well be imagined to be multifold the number of cases of physical abuse. However, a law requiring the reporting of "mental abuse" may be less workable than the "child abuse law." Mental abuse is not a tangible thing.

One might consider custody cases and other cases involving minors -- it is often quite difficult to establish, to the satisfaction of the judge, that parents are so cruel to their children as to warrant judicial action, or when such a fact is established, there is little the court can do about it (except remove the child from custody of the parents). While the court cannot command good parenthood, social casework in conjunction with legal action may sometimes help.

As you know, it may happen that abusive parents will not bring their child to therapy for fear of a report, or they may take their child out of therapy should abuse be reported. A judgment call regarding abuse or possible abuse, rights of the child and confidentiality often times are in conflict.

♦ Child Abuse Law
Some feel mandatory reporting is only the tip of the iceberg. The problem is whether social agencies have the manpower to implement the reports. And, the country's social agencies are now stretched to the limit.

We do not contend that this law is even a partial answer to the problem of child abuse. It is helping to illuminate the startling size of the problem. We think there are many answers to the question of how to stop the problem of child abuse.

Once the child is found, it is up to the whole network of community agencies, which exist for the protection of children, to assume their appropriate roles in being sure that the child is kept from being either killed or maimed by any further action on the part of his parents.

Recent reports show that there is at least a fifty/fifty chance that a beaten child will suffer further damage if vigorous action is not taken on his behalf. If it is necessary to remove him permanently from his home, another home must be found. What is urgently needed now is a general public understanding that these services must exist in every community.

The problem of child abuse is not a simple one. Of course, if the child's parents can be rehabilitated, every effort should be made to be sure that they receive all the help they can use. But, the basic need is to protect the child. In this involvement of a whole network of community agencies and removal from the home, confidentiality risks increase.

- Slovenko, R., PhD. (1997). Psychotherapy, Confidentiality, and Privileged Communication. Illinois: Charles C. Thomas.
- Petrila, J., J.D., L.L.M., & Fader-Towe, H., J.D. (2010). Information Sharing in Criminal Justice-Mental Health Collaborations: Working with HIPAA and Other Privacy Laws. Council of State Governments Justice Center, 1-46. Retrieved from
- Administration for Children & Families. (august 2014). Confidentiality Toolkit. U.S. Department of Health & Human Services, 1-129.

Peer-Reviewed Journal Article References:
Karnani, S. R., & Zelman, D. C. (2019). Measurement of emotional blackmail in couple relationships in Hong Kong. Couple and Family Psychology: Research and Practice, 8(3), 165–180.

Katz, C., & Barnetz, Z. (2016). Children’s narratives of alleged child sexual abuse offender behaviors and the manipulation process. Psychology of Violence, 6(2), 223–232.

Mrkva, K., Cole, J. C., & Van Boven, L. (2020). Attention increases environmental risk perception. Journal of Experimental Psychology: General. Advance online publication.

Tipples, J. (2018). Caution follows fear: Evidence from hierarchical drift diffusion modelling. Emotion, 18(2), 237–247.

Unsworth, K. L., & McNeill, I. M. (2017). Increasing pro-environmental behaviors by increasing self-concordance: Testing an intervention. Journal of Applied Psychology, 102(1), 88–103.

Susie (12 years old) tells the therapist during a session that she has been sexually abused by her father. Susie immediately breaks into tears as she fears the therapist will report it. The first response of the therapist should be to:
a. calm the child and ask for a further clarification of the abusive situation
b. explain to the child that the therapist has no choice, and it must be reported immediately
c. tell the child that it is for the best in the long run, and she must trust the worker
d. explain the legal requirements and what will probably happen to the child as a result if the abuse is currently going on
To select and enter your answer go to Test.

Section 6
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