Confidentiality is a cornerstone of healthy therapeutic relationships and effective treatment and is based upon the ethical principles of autonomy and fidelity, and to a lesser degree, beneficence and nonmaleficence.
Autonomy assumes clients have the right to decide to whom they will reveal information, and confidentiality is based upon respect for clients’ ability to choose what they disclose. Fidelity refers to psychologists’ faithfulness and loyalty to keep promises to clients, including not revealing information clients disclose.
Psychologists are also honest about limits of confidentiality so clients are able to make informed decisions about self-disclosure. Beneficence and nonmaleficence have an important role in confidentiality. Clients benefit when information is kept confidential and a trusting relationship can be achieved. The disclosure of private information without client consent can do harm to the therapeutic relationship even when such disclosures are mandated by law.
Issues of confidentiality are often complex. Members of the American Psychological Association (APA) reported that the most common dilemma for therapists providing individual therapy involved confidentiality. Those dilemmas become even more complex when group therapy is provided.
The APA Ethical Guidelines provide good general information about maintaining confidentiality in therapeutic relationships: “Psychologists have a primary obligation … to protect confidential information … recognizing that the extent and limits of confidentiality may be regulated by law….” Further, “psychologists discuss with persons … with whom they establish a … professional relationship 1) the relevant limits of confidentiality and 2) the foreseeable uses of the information …” and “the discussion of confidentiality occurs at the outset of the relationship and thereafter as new circumstances may warrant.”
However, the guidelines provide little specificity regarding confidentiality in group therapy: “When psychologists provide services to several persons in a group setting, they describe at the outset the roles and responsibilities of all parties and the limits of confidentiality.”
More definitive guidelines are provided by associations specifically dedicated to group work. The Association for Specialists in Group Work in Best Practice Guidelines states: “Group workers define confidentiality and its limits (for example, legal and ethical exceptions and expectations; waivers implicit with treatment plans; documentation and insurance coverage). Group workers have the responsibility to inform all group participants of the need for confidentiality, potential consequences of breaching confidentiality and that legal privilege does not apply to group discussions (unless provided by state statute.)”
Group psychotherapy is a powerful and curative method of psychological treatment, but issues of confidentiality are magnified at least as many times as there are group members. Not only is information revealed to the therapist, it is also revealed to other group members, and there is no guarantee that other group members will maintain confidentiality. However, studies have shown that group members expect complete confidentiality and do not fully understand how confidentiality in group settings differs from confidentiality in individual therapy.
Informed consent is the process whereby clients learn about confidentiality. When group treatment is being considered for clients, education regarding confidentiality should begin prior to entering group. Potential group members should be informed that the group leader may have a legal obligation to break confidentiality in certain circumstances, and those circumstances should be fully explained.
They should also be informed that the group leader can assure confidentiality on the leader’s part (within the constraints of the law) but cannot promise that other group members will maintain confidentiality. Another important issue to discuss is the probable lack of privileged communication. In most states, privileged communication does not exist in group settings due to the third-party rule, which states that information revealed in front of a third party was not intended to be private and is not privileged. Therefore, group members may be called to testify against their peers regarding information obtained in group sessions.
Group members should be encouraged to embrace the concept of confidentiality, making it their own rather than a rule the group therapist has mandated. When new group members join an ongoing group, they may be asked to sign or may have already signed a contract attesting to their commitment to confidentiality.
Confidentiality should become one of the most important group norms, and it should be discussed openly, thoroughly and often among group members. What constitutes a breach of confidentiality should be clearly defined, and consequences for breaking confidentiality should be openly discussed. A common phrase used in group therapy is, “What’s said in group stays in group.”
Issues discussed in group are not discussed elsewhere even if group members live in the same setting. Explaining to group members that their responsibility is to keep their fellow group members’ information private while being able to tell their personal stories to whomever they wish sometimes helps to clarify the concept of confidentiality.
The literature is clear that absolute confidentiality in groups is difficult and often unrealistic. However, if one provides informed consent about confidentiality, educates group members about confidentiality and makes the discussion of confidentiality an ongoing process, the likelihood of breaches of confidentiality among group members decreases, thus giving the group therapist a better chance to uphold the ethical principles upon which confidentiality is based: autonomy, fidelity, beneficence and nonmaleficence.
References available from the author
Kimberly K. McClanahan, Ph.D., is chief executive officer of Pathways Inc. in Ashland, Ky., which provides mental health services and treatment for alcoholism and drug addiction for clients in 10 eastern Kentucky counties. She is also chair of the Kentucky Psychological Association’s Ethics Committee. Her email address is: firstname.lastname@example.org.