Listen to thisThe question sometimes arises as to how, or if, one can provide a confidential counselling relationship for a youth in the context of a team approach to group care.
On the one hand there are those who advocate that there cannot be a confidential relationship between staff and youth when working in group care. On the other hand there is the opinion that youth should be provided with a confidential relationship, in the context of group care, within which to explore themselves, their problems, and relevant issues.
All youth, regardless of the fact that they are in care, have the right to some privacy and confidentiality in dealing with some of their problems: for example, the provisions for confidentiality of communication with certain persons as established under the Youth Protection Act. So, while our society recognizes the rights of youth to confidentiality in some areas, the real question is whether or not such a right can be extended to the individual relationship between youth and staff.
The right to privacy and confidentiality is a human and therapeutic, as well as a legal, consideration. All professions recognize the need for a certain degree of confidentiality in therapeutic relationships in order to establish a trusting environment within which help can be sought and offered. It seems logical therefore, that in their relationship with a staff member, youth should be provided the opportunity for confidentiality of content in counselling.
However, because group care requires a team approach to the treatment of troubled children, the team needs to share information regarding a youth in order to insure effective continuity and consistency in care, support and treatment. It is in this area that the counselling relationship between staff and youth in group care environment differs, for example from the relationship between individual therapist and their client or between a doctor and a patient. Yet, youth must feel that they have a relationship within which they can explore, with confidentiality, areas of interest or concern to them. The ultimate question then becomes, “if we provide a confidential relationship between staff and youth, what, of necessity, are the limits that must be placed on the degree of confidentiality which can be maintained?”
The stipulations for ethical practice of other professions offer us some guidelines. Staff have a moral responsibility to violate a confidential relationship in cases where they believe that a youth is engaging, or going to engage, in a behaviour which is dangerous for themselves or others. For example, if a youth has suicidal ideation and intention, the staff has no choice but to ensure that all members of a team are aware of this. Therefore, we can safely say that the first guideline we must establish would be that we cannot provide confidentiality for youth when they reveal to us information which suggests that they or someone else may be at risk.
Second, we have legal obligations not to provide confidentiality when certain kinds of information are revealed to us. For example, if we suspect that a youth has been physically or sexually abused, we have a professional responsibility, supported by law, to report that information to the appropriate persons. This is true, even though the danger of continued abuse may be minimal.
Finally, it is obvious that when information is provided to us by a youth that is essential for all members of the team to have, in order to provide appropriate treatment we must share that information with our team colleagues. If the failure to provide information to our colleagues will result in the failure to provide adequate treatment for the youth, we obviously need to share this information.
The secret-trap
The secret-trap is a phenomena which can exist in human relations when
one of the parties to an interaction solicits and receives from the
other party a commitment to confidentiality or secrecy prior to
revealing certain information. The following example represent this
phenomena:
George, a youth in a group home program, and a child care worker are involved in one of their regular counselling sessions. During the course of the session the following interaction occurs.
C.C.W.: “So, George, how did things go for you at home this last weekend?”
George: “Well, they went okay, except, ah, well, hum,...”
C.C.W.: “George, it sounds like something unusual might have happened this weekend. Can you tell me about it?”
George: “Well, I'm a bit embarrassed to say.”
C.C.W.: “Well, why don't you give it a try, and I'll see if I can help you with your embarrassment.”
George: “Okay, but,... I don't want anyone else to know about it.”
C.C.W.: “What do you mean?”
George: “Well, if I tell you, you won't tell anybody else, will you?”
C.C.W.: “Look, George, if it's really important to you, I guarantee you that it will stay between you and me.”
George: “Well, okay. On Saturday night, when my mom was out, I took some of her sleeping pills and gave them to my sister. She got really tired and went to her bedroom and went to sleep, and, ah, well, after she was asleep I went to her room and, sort of, you know, touched her ...”
The “secret-trap” now exists for the worker. He is now faced with the dilemma of having guaranteed secrecy and at the same time having the professional responsibility to violate that guarantee. He is trapped between the commitment to confidentiality to George, and the commitment to treatment, safety and professional ethics. Potentially, this trap generates the risk of damage to the youth, to the relationship between the youth and the worker and to the youth's effective treatment. If the worker now tells George that he has no choice but to report the information, George may be understandably angry and hurt that this adult has promised him confidentiality, he has taken advantage of the promise, and now the promise is to be broken. In this case we might expect George to respond with withdrawal, increased lack of trust in adult relationships, acting out, or other signs of hurt and anger.
The trap only exists because the inter-personal rules about confidentiality were not clear from the beginning, nor were they made clear at the time of the specific interaction.
Prior to entering a counselling relationship with a youth it must be made clear that there are certain limits to the degree of confidentiality which can be offered. Failure to make the limits clear before entering into the counselling relationship sets up the potential for future conflict between the youth and the worker. Failure to reiterate the limits of confidentiality during an interaction such as the one above further compounds the difficulty.
Once we have agreed to confidentiality and we need to violate that commitment, it is we who are trapped. If we continue to maintain the confidentiality it puts the youth in control of the relationship and sets us up for tension in our relationships with our other colleagues. For example, if in the case above, the worker was to maintain confidentiality and the issue of the relationship between George and his sister was to arise in a team meeting, s/he would be forced to develop a dishonest relationship with other team members in order to collude with George in the maintenance of this secret.
The secret-trap has the potential to place the worker in a conflictual relationship with their colleagues, teach George that he can manipulate others, put George in control of the relationship between worker and child, create triangulation between George, the worker and other team members and, ultimately, render the worker ineffective.
Levels of confidentiality
It is obvious that there are certain areas in our counselling
relationships with youth where we cannot provide confidentiality. It is
also obvious that not all content areas of the counselling relationship
between worker and youth need to be shared with the whole team. For
example, if a youth wishes to share in a counselling relationship some
of their feelings of inadequacy around developing a relationship with a
new boyfriend, it may not be important that all of that information is
shared with the team. There are, therefore, distinctions to be made.
These distinctions need to be made in the context of a team agreement
about the levels of confidentiality they are able to provide for
youth in the context of a team approach.
Teams need to discuss this area and come to a common agreement about what level of confidentiality they are prepared to provide for the youth in their care, bearing in mind that some information can never remain confidential. Once the parameters of this confidentiality are defined these limits must be shared with all youth, prior to entering into a counselling relationship with a worker.
The failure to provide any confidentiality for youth, may lead to a situation where some youth are reluctant to share any information with workers, in the knowledge that, if they should share it, everyone will know within a few days. On the other hand, for their own safety and treatment, all youth must know that while we will provide them with a confidential counselling relationship, we will do so in the context of their best interest and we will therefore establish limits to what will or will not be shared with other team members.
The semblance of confidentiality
A final comment must be made about how we handle, on a day to day basis,
intimate personal information which we receive from or about youth in
our care. While it may be necessary for us to know certain information
about a youth, their family, or their activities, it is not always
necessary (nor advisable) for all team members to demonstrate to the
child that they are aware of all information.
For example, even if we have been clear with youth at the time of their entering our program about the limits of confidentiality, and even if they know, after having told us some information, that we need to share it with the whole team, the youth can be allowed to continue to live in the program, at least in some cases, with the semblance of confidentiality and privacy even though they may know that all team members are aware of the information.
For example, if all team members are aware that a child has been sexually abused by one of their parents, it may be best for discussion about this abuse (and reference to it) to occur only in the context of a relationship with one team member as opposed to being the subject of discussion with all team members. The same may hold true for other forms of confidential information which we hold.
Expanding the circle of knowing
Another area which needs to be addressed, is the question of how we help
a child to reveal information to other persons, which they have revealed
in the context of their relationships with us. For example, if a youth
has revealed to us that they have had an experience which they wish to
share with one of their parents, or another professional, we may need to
spend time with the youth around the issues of how the information will
be shared, what we can do to support them in sharing the information and
what some of the possible outcomes of sharing the information might be.
People can only share information at the rate which is acceptable to them and we must be sensitive to their ability to share. Information which is shared with others prior to the youth being properly prepared, is often information which is retracted at a later date. It is important that we recognize that a supportive and facilitative approach reduces the threat, and increases the level of security, for the youth involved.
In the context of clarity about confidentiality, support for the person and their experience, and sensitivity to the human elements involved, youth can find the safety and security within which to help them deal with confidential information in a way which will allow them to grow and develop more effectively in the world around them. It is our responsibility to ensure that our relationships with them are conducive to this growth.
