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Section 9
Kentucky Administrative Regulations: 201 KAR 23:080
Confidentiality

Question 9 | Test | Table of Contents

     Section 9. Confidentiality. (1) A social worker shall hold communications with a client in confidence and shall maintain a record of client information in a confidential manner.
     (2) A social worker may disclose client information if:
     (a) The client has signed an authorization to release information;
     (b) The social worker is required by law to disclose essential information out of a duty to protect, warn, or report;
     (c) The social worker is a defensant in a civil or criminal action or is a respondent in a disciplinary process; or
     (d) A client has raised his mental condition as an element in a civil action and the court has ordered the release of the client's information.
     (3) A social worker shall not disclose more client information than is necessary to meet the requirements of law.
     (4) A social worker shall remove identifying information about the client from a training manual. professional writing, or classroom presentation.
     (5) A social worker shall protect the confidentiality of a deceased client.

- Kentucky Legislature. Title 201, Chapter 23: 080 Board of Social Work. 2018 Kentucky Administrative Regulations. Section 9. Confidentiality.

Commentary by Pamela Newsom, Kentucky LSW:
The limits of confidentiality might be different if you are in a practice by yourself compared to working in an agency, school, or a hospital setting. Many of the individuals who are receiving their license are not sitting down and providing therapy to clients, rather they are case workers or working in a school which can potentially cause issues in regards to how far you can go in terms of confidentiality. At the same time, you have to go far enough to protect your client and provide your client with the best possible care, even if that means that it cannot be you who provides that service to the client.

In the latter types of settings previously listed, you know that your clients will come into contact with other people that work there. So you have to ask yourself, "What are the limits in regards to sharing the client's information?" That client may view your sharing information with a coworker as a disservice or a breach of their privacy. An example for when you may need to share a client's information with a co-worker is if the student, client, or family is not comfortable going to another social worker, but there is another social worker or other professional who is aware of the client's present situation, then you, with the client's or family's permission, may talk to a co-worker and make them aware of the situation.

Regulation 201 KAR 23:080 states, " A social worker shall hold communications with a client in confidence and shall maintain a record of client information in a confidential manner."

Limits of Confidentiality
Until recently, there were few generally recognized and accepted exceptions to complete confidentiality in the practice of psychotherapy (Beck, 1990). Early breaches of confidentiality were normally made in the patient's interest, such as when civil commitment or consultation with a treatment team was needed (Beck, 1990). Over time, however, the right to absolute confidentiality has been more difficult for psychotherapists to maintain. There have been dramatic increases in the legal and ethical dilemmas that have tested the limits of confidentiality in the therapist-client relationship (Boylan, Malley, & Scott, 1995). Unlike earlier cases where confidentiality was breached, these limits to confidentiality are not necessarily intended for the benefit of the client (Beck, 1990).

Boylan et al. (1995) believed that changes in the legal mandates led to changes in the ethical codes under which professionals operate. They cited three legal constraints that have been placed on therapists that have directly impacted the limits of confidentiality in the therapeutic relationship. The first is the famous Tarasoff v. Regents of the University of California (1976) case, in which the court held that therapists might need to breach confidentiality to protect third parties who may be in danger from a client being seen in therapy. The second legal constraint is the enactment of mandatory child (and elder) abuse reporting laws, which require therapists to breach confidentiality. The third legal consideration is the lawsuits brought against physicians and institutions for failing to provide adequate care to suicidal clients or patients. Beck (1990) noted that the requirement for psychotherapists to report information to third-party payers as a condition of payment is another change that has affected the limits of confidentiality. The changes in the legal climate and in ethical thinking have led therapists to view confidentiality in the therapeutic relationship as limited and no longer an absolute.

Although no longer all encompassing, confidentiality remains one of the cornerstones of the therapeutic relationship (Remley & Herlihy, 2001). Clients need to be educated about confidentiality, privileged communication, and privacy to ensure trust in the therapeutic relationship (Corey, Corey, & Callanan, 1998). One of the best ways to accomplish this is through the process of informed consent. Bednar, Bednar, Lambert, and Waite (1991) stated that it is essential for clients to understand the treatment that will be provided to them and to give their consent voluntarily and that it is the responsibility of the therapist to assess the level of the client's understanding and to make sure the choice to enter counseling was made freely. The limits of confidentiality are an important element of any informed consent.

Clients need to be aware that confidentiality and privilege belong to them, not the therapist. As such, clients have the right to waive their privacy. Clients may ask a therapist to release information regarding the therapeutic relationship to third parties (Remley & Herlihy, 2001). According to Knapp and VandeCreek (1987), clients may also implicitly waive privilege and confidentiality if they file a lawsuit or malpractice suit against a professional.

Duty to Warn
The most well-known limit to confidentiality—but one that still needs to be explained to clients—is that the therapist may decide to break confidentiality in cases where the client makes threats to harm others. In 1974, the California Supreme Court ruled in the Tarasoff case that a psychotherapist has a duty to warn third parties who have been threatened by a client being seen in therapy (Felthous, 1989). In 1976, the court issued a different holding that resulted in a broader, more robust announcement. The court held that the therapist's duty was to protect the intended victim, rather than to warn (Bednar et al., 1991). Although the Tarasoff doctrine only applies in the state of California, many states have adopted similar laws, and therapists must have knowledge of their current state laws (Knapp & VandeCreek, 1993).

Similarly, although there may be no legal duty to do so in a particular state, therapists have an ethical duty to protect clients who may be a harm to themselves due to mental illness. In terms of preventing harm, Furrow (1980) discussed the duty to prevent suicide in a hospital, the duty to control dangerous conduct, and the duty to protect. A therapist must exercise reasonable care to prevent foreseeable harm or danger that may result from a client's mental or physical incapacity (Furrow, 1980). The courts have upheld that an additional duty to protect a client is established when the client is a danger to themself (Bongar, 1991). The duty to protect has been upheld by the courts many times for clients who were hospitalized (Bongar, Maris, Berman, & Litman, 1992). It has been more difficult to hold a therapist responsible for the actions of an outpatient client (Furrow, 1980).

In addition, there are instances when the therapist may need to share client information with others. In these instances, Remley and Herlihy (2001) suggested that the "umbrella" of confidentiality be extended to cover other people. Potentially, clerical staff and other employees may handle confidential client information. In these cases, the therapist is responsible for any breaches of confidentiality that may take place. In some cases, therapists may need to consult with fellow colleagues or experts in a particular area. Although this potentially can be accomplished without revealing client identity, there may be times when providing such information is unavoidable. In these situations, it would be wise for the therapist to inform the client (Remley & Herlihy, 2001). A final instance where confidential client information is shared is when the therapist is working under supervision. One difference is that in this situation the client's identity cannot be concealed (Corey et al., 1998). Therapists in training have an ethical obligation to disclose to clients that they will be working under supervision and that confidentiality is limited (Remley & Herlihy, 2001).
- Werth, James, Burke, Caroline, & Rebekah Bardash. Confidentiality in end-of-life and after-death situations. Ethics & Behavior. Jul 2002. Vol. 12; Issue 3.

Ethical Decision Making, Therapeutic Boundaries, and Communicating
Using Online Technology and Cellular

- Yonan, Jesay. Ethical Decision Making, Therapeutic Boundaries, and Communicating Using Online Technology and Cellular Phones. Canadian Journal of Counselling and Psychotherapy, 2011, Vol. 45 No. 4, Pages 307–326.

Personal Reflection Exercise #1
The preceding section contained information about the limits of confidentiality.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Allen, L. R., & Dodd, C. G. (2018). Psychologists’ responsibility to society: Public policy and the ethics of political action. Journal of Theoretical and Philosophical Psychology, 38(1), 42–53.

Cox, J. R., Martinez, R. G., & Southam-Gerow, M. A. (2019). Treatment integrity in psychotherapy research and implications for the delivery of quality mental health services. Journal of Consulting and Clinical Psychology, 87(3), 221–233

Esposito, G., Passeggia, R., Cutolo, A. S., Karterud, S., & Freda, M. F. (2020). Treatment integrity and members’ change in group counseling: A pilot study on counselor’s mentalizing interventions. Professional Psychology: Research and Practice.

Moss, L. S. (2017). Collaboration, confidentiality, and care. Psychological Services, 14(4), 443–450.

Nielsen, B. A. (2015). Confidentiality and electronic health records: Keeping up with advances in technology and expectations for access. Clinical Practice in Pediatric Psychology, 3(2), 175–178. 

Ware, J. N., & Dillman Taylor, D. (2014). Concerns about confidentiality: The application of ethical decision-making within group play therapy. International Journal of Play Therapy, 23(3), 173–186.

QUESTION 9
 Clients need to be educated about confidentiality, privileged communication, and privacy to ensure trust in the therapeutic relationship. What is one of the best ways to accomplish this? To select and enter your answer go to Test.

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