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In this section, we will examine three controversies resulting from concerns about confidentiality boundaries. These three confidentiality controversies include: fear of disclosure; loss of trust; and HIPAA hypocrisies.
3 Controversies Resulting from Concerns about Confidentiality Boundaries
♦ Controversy #1 - Fear of Disclosure
The first confidentiality controversy is fear of disclosure. In general, clients who are hesitant to seek counseling become so out of a fear of disclosure to the general public.. A great number of potential clients have the erroneous idea that therapists are likely to let slip the delicate information revealed during a session. Many believe that therapists may laugh and joke to other colleagues about embarrassing stories.
Irene, age 61, had developed a distrust of doctors, and therefore any professional related to the healthcare system. Because of this, when her nursing home referred her to me for acute depression, she was reluctant to talk to me. She stated, "I know you doctors. You sell our information on the internet to web hackers and don’t give a damn if they come in the middle of the night for our kidneys! No one can stop you, can they?" I gave Irene a copy of the HIPAA guidelines and my Notice.
I stated to her, "I cannot decide to share your information if that situation is not covered in my Notice. You have to give me permission, or else I would be breaking the law." Irene stated, "You mean I tell you what to do and when to do it?" When I answered yes, Irene became more open to discussion. Think of your Irene. What information could you share with him or her to alleviate fears of disclosure?
♦ Controversy #2 - Loss of Trust
The second confidentiality controversy is a loss of trust between counselor and client. Sometimes, and against our will, the law or ethics require healthcare professionals to reveal client information. These instances can include legal subpoenas or reports of threats. When this occurs, the client may feel betrayed by his or her therapist or social worker to such a point that trust within the client-therapist relationship has completely deteriorated.
As a result, it becomes very difficult for the client to continue treatment when he or she does not fully trust the therapist or social worker. They may hold vital information back and therefore may never recover. However, if a client posed a serious threat to his or her health or the health of those around them, then the disclosure may have been necessary to save the client’s or a loved one’s life.
Terry, age 15, had threatened to harm his older brother, Phil, because Phil had always received the most praise in the family. Terry, who diagnosed with borderline personality disorder, stated, "I hate that faggot! I wish he would die, I might just smother him with a pillow tonight!" Although I was not entirely convinced that Terry would resort to violence, I still opted to warn his parents about his threats against his brother. They confronted Terry, and Phil was sent to live with an aunt for a week.
Although the immediate danger had passed, Terry felt betrayed by me for warning his parents. He stated, "You’re just like the rest of them! You don’t care about me, and maybe I don’t deserve it. I guess I’m going to hell. Satan must have a condo waiting for me. Why don’t you just leave me like the rest?" Much of what Terry said came as a result of his disorder. I stated to Terry, "But I’m not leaving. I’m still here and I have no intention of sending you off to another therapist. I wanted your parents to know what you said because I was concerned for you. If you had actually done harm to your brother, you may have passed a point beyond which I can no longer help you."
Terry stated, "I wasn’t really going to hurt him." I asked, "Then why did you say that you would?" He responded, "I don’t know. I was angry and I needed to vent." I then stated, "Well, perhaps we should find a more productive and less harmful way to vent our anger." Think of your Terry. Has there been a loss of trust as a result of a confidential disclosure?
♦ Controversy #3 - HIPAA Hypocrisies
In addition to fear of disclosure and loss of trust, the third confidentiality controversy is HIPAA hypocrisies. As you are aware, HIPAA refers to the Health Insurance Portability and Accountability Act enacted in 1996. It provides certain guidelines and regulations regarding the disclosure and sharing of client’s information and claims to protect the client’s interests. However, although, the legislation presents all appearances of attempts to protect a client’s privacy, upon closer scrutiny, it becomes apparent that certain passages may contradict each other.
Most specifically, HIPAA expert Michael Freeny points out a specific section within the legislation which guarantees consumers the right to see and copy their health records and request corrections of mistakes that may be contained in those records. However, providers are obligated by HIPAA to inform clients that they are not bound to fulfill such requests. Therefore, the client’s rights may not be recognized by the provider if the provider deems it unnecessary. In addition, the guidelines stipulate that clients maintain the right to restrict the distribution and transmission of their medical information.
However, Freeny points out, "It’s not true because the next sentence says that the provider is under no obligation to give you that information." Even further, although the client may retain the right to restrict the distribution of their information and the provider consents, there are certain entities to which the provider cannot deny access, specifically the federal government, police, and public health agencies. So although HIPAA may appear to be more restrictive regarding the distribution of records, this restriction only applies to certain individuals not among the HIPAA approved agencies. Think of your clients. Can you think of any clients who may be shocked by the extent to which the government has access to his or her records?
In this section, we discussed three controversies resulting from concerns about confidentiality boundaries. These three confidentiality controversies include: fear of disclosure; loss of trust; and HIPAA hypocrisies.
Peer-Reviewed Journal Article References:
Benefield, H., Ashkanazi, G., & Rozensky, R. H. (2006). Communication and records: Hippa issues when working in health care settings. Professional Psychology: Research and Practice, 37(3), 273–277.
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.
Forrest, L., Elman, N. S., Bodner, K. E., & Kaslow, N. J. (2021). Trainee confidentiality: Confusions, complexities, consequences, and possibilities. Training and Education in Professional Psychology.
Ponce, A. N., Aosved, A. C., & Hill, K. (2021). Facilitation of consultation and communication between psychology doctoral programs and internships. Training and Education in Professional Psychology, 15(3), 189–194.
Richards, M. M. (2009). Electronic medical records: Confidentiality issues in the time of HIPAA. Professional Psychology: Research and Practice, 40(6), 550–556.
Stiles, P. G., & Petrila, J. (2011). Research and confidentiality: Legal issues and risk management strategies. Psychology, Public Policy, and Law, 17(3), 333–356.
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