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Revisiting confidentiality: observations from family therapy practice

Daniel Paul Wulffa, Sally Ann St Georgea and Fred H. Besthornb

Confidentiality has long been recognized as a critical legal and ethical principle for the committed, value-based practitioner. Vital principles (such as confidentiality) become manifest in material practices and in the language of professional and societal narratives. This articulation into specific practices and performances requires a pragmatic process that transforms the abstract into real-world activities. This imperfect process has the potential of including the derived practices that in certain ways may extend the principle in unintended or unwanted directions. In the case of confidentiality, the actual practices of confidentiality may be both emancipating and inhibiting – they may protect as well as isolate. Our purpose is to revisit the idea of confidentiality and to deconstruct the way it functions in both positive and negative manners in clinical work.

Keywords: confidentiality; societal narratives; community-minded family therapy.

It is never easy to undertake a critical review of a topic that most people believe to be a fundamental dimension of effective helping. The principle of confidentiality is one of those ideas that appears to be so sacrosanct as to be beyond purposeful and serious questioning. Our view is that critical reflection on any practice strategy, policy initiative or ethical standard in the helping professions is not only appropriate but necessary in order to ensure that those practices, policies and ethics continue to support the goals they were created to meet. ‘It is quite healthy for a profession and its members to question theory and operation. Without constant assessment and evaluation, the profession can become stagnant and antiquated’ (Vesper and Brock, 1991, p. 148). In this article we consider how one of our professional helping canons – confidentiality – may at times inadvertently serve to

Journal of Family Therapy (2011) 33: 199–214 doi: 10.1111/j.1467-6427.2010.00514.x

a University of Calgary, Faculty of Social Work, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, Canada. Corresponding author e-mail: [email protected].

b Department of Social Work, University of Northern Iowa, Cedar Falls, Iowa, USA.

r 2010 The Authors. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice. Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA.

J O U R N A L O F

FAMILY THERAPY

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constrain our work with families and impede families’ own initiatives for growth.

First, let’s take a moment to reflect upon the conventional notion of confidentiality. Over time it has tended to become a kind of uni- versalizing narrative, so accepted and acceptable precluding any need for critical review or careful reconsideration – it has achieved the status of a given. When discussing confidentiality the notion of privacy is often conflated with the notion of confidentiality. But, according to Clark (2006), ‘[p]rivacy and confidentiality are different qualities: the one refers to a status while the other refers to the terms of a communication’ (p. 127). Thus, in practice, we see confidentiality as a negotiated practice strategy that functions as a means to an end – of assuring protected patterns of open communication. Vesper and Brock (1991) point out that ‘the successful clinician encourages the client to disclose information that may be disconcerting. To obtain such guarded information, the therapist must be able to assure the client of strict confidence’ (p. 55). Confidentiality is an arrangement that a therapist has with a client that invites the client to disclose sensitive information required by the therapist to conduct effective therapy, with the proviso that the therapist will not reveal that information to anyone else.

There can be little doubt that the conventional idea of confidenti- ality has served an important protective function for individuals and for many in the larger community. This protective function is not always advantageous when viewed from the different perspectives of other cultural traditions or social conventions. ‘[T]he rights to privacy and to give informed consent that are now so prominent in Western society may seem quite foreign in cultures that have fundamentally different views of boundaries between people and those in authority positions’ (Reamer, 1995, p. 38). Moreover, Moore-Kirkland and Vice Irey (1981) point out that people in rural communities, closely knit urban communities and residential set- tings are ‘intricately related through family ties, historical events, and high visibility of behaviour’ (p. 320) that make strict confidenti- ality next to impossible, even if pursued. Indeed, there is a growing recognition that numerous cultural, religious and regional differ- ences exist with respect to how privacy and confidentiality have come to be understood in disparate parts of both the Western and developing worlds. Despite this, the fact remains that modernity’s foundational idea of the self-contained, private individual – operat- ing in a largely private, rigidly demarcated social world and legally

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protected from unwanted probative inquiry – is closely associated with how the principles of privacy and confidentiality have come to be interpreted and applied in Western society (Besthorn, 2002).

There have been frequent efforts in family therapy, social work and psychology that have stretched the focus of the therapeutic change beyond the individual client or even the individual family to include the larger social network of that client (for example, Auerswald, 1981; Seikkula et al., 1995; Speck and Attneave, 1973).

Speck and Attneave, whose therapeutic approach is dependent upon the active involvement of a client-family with friends, relatives, work associ- ates, and others in the natural environment, contend that the lack of confidentiality contributes to the effectiveness of network therapy. As channels of communication open within the social network, members experience relief from sharing private burdens and develop trust in one another. . . . New information and open communication can present an opportunity for the total system – family, neighbourhood, and commu- nity – to develop new ways of dealing with each of its parts on a realistic basis.

(Moore-Kirkland and Vice Irey, 1981, p. 321)

Efforts to protect an individual’s right to confidentiality have also had the unintended consequence of privileging certain preferred ther- apeutic modalities and limiting others. Those modalities that are grounded in an individual approach and based on securing informa- tion within a one-to-one therapist–client relationship have been more accepted, while using modalities that are grounded in a context of more expansive conversation among larger networks of individuals have been seen as suspect or problematic.

‘By concealing information . . . [the therapist] defines family and society as separate entities with conflicts of interest’ (Haley, 1977, p. 199). Conventional ideas of confidentiality thus become a mechan- ism to develop and maintain a division between a family in therapy and the larger context in which they live, encouraging a view that they represent differing, and sometimes competing, interests. Keeping clients separated from each other in their own privately constructed and idiosyncratic worlds also prevents them from coming to know and learn from each other. This client separation or privacy is derived from the idea that each family has a problem that is most efficaciously ameliorated by a therapist behind closed doors. Other families struggling with similar issues are not considered as resources or seen as able to offer the kind of significant help that is generally

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understood to be afforded only by a professional therapist. This situation is not uncommon in family therapy practice, despite the fact that support groups have a long and rich history in producing networks of information and mutual support for members that seriously challenges the notion that people in distress cannot be a significant resource for others in distress (Steinberg, 1997; Whitaker and Garbarino, 2005). Additionally, it may well be that this resource may be as useful to those giving help as it is to those receiving it (Pilisuk and Parks, 1986).

We have experienced a number of situations over the years in which carefully circumscribed ideas of confidentiality have, in our view, been directly associated with prolonging distress and inhibiting clients and communities from addressing important issues. We have also experienced situations with clients in which traditional (or usual) practices of confidentiality work well. We are not advocating a whole- sale change in how confidentiality is understood and used for all clients. Simply put, we have seen some situations in which confidenti- ality was not as helpful as we hoped it would be. In this article we examine how confidentiality, despite its significant usefulness in protecting client information and protecting clients from the consequences of others knowing their personal situation, may be implicated in restraining families and therapists from reaching improved levels of health and well-being. The examples that follow are illustrative.

Should Madeline and Betty meet?

Madeline was a refugee single mother from Colombia with two adolescents and two younger children. I (SSG) first met Madeline and her children through a neighbourhood service group dedicated to helping new refugees settle into our community. Working with a neighbour, my intention was to help Madeline and her children with daily activities and to negotiate, successfully, a new life in a foreign country. I saw the family regularly, provided basic staples of living and transportation, and became good friends.

Betty was a single mother with three adolescent children of her own and two young nieces at home; she was of mixed race (Caribbean and Aboriginal) and I was her family therapist. Betty was unemployed, poor and lived in crowded housing. She had to rely on public

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transportation and struggled to keep her children safe, in school and out of trouble. Managing these children was an enormous task; the family was preoccupied with issues surrounding developmental delays, drug experimentation, bullying and discrimination. My clin- ical work with Betty’s family was primarily in her home but included a great many collaborative contacts and meetings with other helping professionals who were also working with this family.

Several months after Madeline’s arrival to Canada she had fallen on the ice and broken her hip. It was determined that she needed surgery to correct the injury and so my neighbour and I became involved in making arrangements for childcare during her hospitali- zation and recovery. The recovery did not go well as she developed a serious infection. Madeline was once again hospitalized and her condition did not seem to improve. In the midst of this major crisis with Madeline, I decided to ask Betty (an openly religious person who often spoke of the power of prayer) if she would pray for a sick mom (Madeline). Betty’s response was an unequivocal yes and, further- more, she said she would ask her congregation to pray for the sick mother as well.

Each time I went to Betty’s house she would ask how the sick mother was doing. Unfortunately, more complications developed and Madeline’s spirits were sagging, in part because she still had difficulty with speaking English. Madeline was also a devout woman and I often told her that she was being remembered in prayer by many people – colleagues, my family and even some mothers that she did not know. Madeline believed that was her only hope.

Two weeks after Betty began praying for Madeline she said to me, ‘I want you to take me to the hospital to be with this sick person. I want to minister to her’. I was unsure how to respond, and therefore told Betty that the sick person would need to be consulted as to whether she was agreeable to the visit or not (figuring that this would give me time to think about the confidentiality issues involved). When con- sulted about Betty’s offer, Madeline was delighted and said, ‘Yes, of course, that would be wonderful’.

Up to this point, I had not revealed the identities of either Madeline or Betty to each other except in a generic way (a ‘sick mom’ and ‘a mom raising kids alone who prays for you’). However, they both knew my profession. On a human-to-human level, I believed that it made perfect sense for one woman to help care for another. I consulted a few colleagues who concurred with me, believing that it was non- sensical to prevent a person from reaching out to help another in such

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dire need. Keeping Betty’s identity confidential became less im- portant than the potential benefits of these two women meeting. Madeline would receive support and encouragement and Betty would benefit from reaching out to help someone. But I was now bringing together these two women face-to-face, one of whom was a client and the other a friend.

I anticipated that the meeting would last about an hour. Betty emerged from her house with a bag that looked much like a medical bag doctors used to carry when they went to their patients’ homes. Betty said that she was bringing a candle, ointment, comb and brush, mints, herbal tea and a prayer book. When they were introduced, the women talked for a few minutes about how many children they had, where they were from, and then Betty instructed Madeline to rest and let her (Betty) do her ‘work’. Madeline closed her eyes and gave herself over to Betty who, after setting the atmosphere with a candle, massaged her body with ointment and brushed her hair, all while praying or humming. I only watched in amazement. Nurses came in and silently took their monitor readings, not wanting to disrupt. When the body treatments were complete, Betty proceeded to quietly sing. Madeline fell into probably the most comfortable slumber she had had in weeks; Betty packed her bag, left the mints and tea and went out.

Madeline and Betty did not meet again. Madeline improved and fully recovered. It could have been the medical treatments, the extraordinary care provided by the nursing personnel, praying, Betty’s visit, and many other attempts to help. Madeline would occasionally ask about Betty and say she was praying for her and her family; Betty would do the same in regard to Madeline.

The church that wanted to help

With a few other colleagues we (SSG and DW) had begun what we called a ‘public practice’ that we referred to as the ‘Community- minded family therapy project’. It was a project that allowed us to work with client families who were slipping between the cracks of services, or were homeless or marked as failures in the social service delivery system. As we were not working under the auspices of an agency or institution our work was wholly informed by ethical guide- lines, our preferred practices and the clients’ expectations and wishes.

We were lucky to have a church that wanted to help us with our project by offering us the use of their building space for family or other collaborative meetings. After a few months we returned to the

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church board to report on the progress of our work. At this meeting the parishioners and board members said that they would like to help our efforts, not only by letting us use their space but in other ways. They offered their time and their talents. We could and should feel free to use them to help the families we were serving. Now how would this fit with confidentiality?

Our group met and we clearly saw that the families we worked with needed many forms of assistance. They had no transportation, the children were in need of academic tutoring and the parents were in desperate need of respite. We saw a church community of people who had transportation, time and interests that matched those of the families. So what was our hesitation? We harboured a concern that joining families who were our clients with volunteer helpers was breaching the confidentiality of our clients. The confidentiality of our relationship with our clients and exposing our client families to volunteers seemed worrisome. Yet, it made so much gut sense to arrange for these people to come to know each other. Why the disparity between what our common humanity told us and what professional confidentiality said? We wondered if broadly held beliefs or grand societal narratives regarding privacy and confidentiality were creating a gap between what our hearts told us and what the professional codes of conduct told us.

We knew that we were not miracle workers who could unilaterally transform people’s lives and we knew that a time would come when we would not be in these families’ lives. We began to think of our role as helping to connect people with people. If we did not have this worry of keeping clients’ troubles privatized in order to comply with strict confidentiality, we could feel comfortable with a decision to join our clients with generous church members. This intersection of church members’ genuine desire to help and the families’ need for support systems provided a possibility that could serve the desires and wishes of both sides.

Clergy sex abuse

This illustration is somewhat different from the preceding two clinical examples. The reason we include it here is to show how maintaining confidentiality at micro and macro levels can have deleterious effects on front-line practice.

During 2002 a series of reports appeared in our local paper that outlined a widening revelation of sexual abuse incidents involving

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Catholic clergymen abusing children and adult women (Smith, 2003). These reports revealed a pattern of sexual abuse by local clergy that had been going on for over 30 years without the knowledge of anyone but the clergy, clerical administrators and the victims and their families involved. Because of the shame involved in such incidents many victims and their families were more than ready to keep the incidents out of the public spotlight. The church also had a vested interest in keeping these stories from being more widely known.

Confidentiality protected the secrecy surrounding these incidents but a by-product of this secrecy was that the community at large was totally unaware of what was happening in their midst and the context in which these problems could re-emerge again and again. The privacy afforded to this situation provided the soil in which the problem could continue. Only when the public became aware of the magnitude and frequency of these incidents did the church respond to take steps to put a stop to further such episodes.

This illustration reveals the difficulty in managing confidentiality in the individual context when successful management at that level may produce the context for future abusive episodes with other indivi- duals. How do we professionally respond to the needs and wishes of the individual(s) in the immediate case of abuse and simultaneously avoid contributing to the probability of similar abuses in the future? The linkage of these two issues (present occurrence and future probable occurrences) is troublesome but to separate them as if they were two unrelated issues unfortunately provides a fertile context for the perpetuation of this problem.

Family therapists who work with families involved with the legal system on such issues as child abuse or domestic violence face this public–private dilemma. Maintaining tight confidentiality protects the privacy of their client (either victim or perpetrator) while simulta- neously keeping other parties unaware of it, which potentially could be problematic for them in the future, depending on the success (or lack thereof) of the therapy. This is not to suggest that therapy should be opened to the public but to highlight the way in which our current system of confidentiality is not completely sufficient.

Isolation as an unintended consequence

These three illustrations highlight for us how confidentiality, as traditionally understood and implemented in our field, can encumber our thinking and our ability to act as creatively and broadly as we

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might. In each of these examples we could see and feel the impact of an unwavering confidentiality standard in restraining information, relationships and our own thinking; in effect, serving to restrict or close down ideas and options. In addition to restricting our creativity we noticed in our two clinical examples a progressive development of feelings of separateness and isolation. By isolation we mean the sense of being the only one to experience something; that no one else knows about one’s troubles and that no one cares. It is not an uncommon experience to be in close connection with many people but still feel alone. In his book, The Dark Child, Laye (1994) says it thus: ‘There had never been so many of us, but I had never felt so alone’ (p. 142).

The three situations we have described have prompted us to consider how larger policies, practices or discourses or narratives might be involved in our clinical work. These may facilitate change but they also might maintain the status quo. We have often heard colleagues (and ourselves) use terms or concepts such as: self-suffi- ciency, self-efficacy, independence and ego-autonomy (less frequently) as unquestioned goals in working with clients. We have began to wonder whether operating under the metaphor that all clients needed to be self-sufficient to be successful was contributing to growth or restraining it. In the light of our current practice, which confirms that bringing clients together with other people can be helpful, it appears to us that the conventional notion of confidentiality is built upon the modern socio-political foundation of autonomy, individualism, sepa- rateness and self-sufficiency; prominent belief systems for those of us in the West. This narrative or belief system generally suggests that people should be free from interference from others and that they should strive for and be independent in order to be considered healthy and worthy as citizens and self-actualized as human beings.

Our experiences in practice helped us to question the indepen- dence–isolation narrative and to wonder if it worked counter to what a family presenting for therapy most needed. As we raised these questions we heard our clients’ words replay in our minds: ‘I need a village’ and ‘I don’t need a six-month intensive program, I need help all along the way’ and ‘we will never get out of the system because they think a single mom with no job is not going to be able to support her family alone’ and ‘are we the worst family you have ever seen?’ and ‘we are a poor family, not a stupid one’ and ‘discrimination will only let us get so far’. We wondered if these statements high- lighted what might be considered the shadowy side of confidentiality and its largely unconscious reliance on powerful Western values of

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independence and autonomy. Each statement reflected to us a marginalization and a significant sense of isolation.

What if we described the grand narrative of individualism as both a good thing (self-sufficiency and independence) and as a troublesome thing (isolation and aloneness)? If isolation were the tarnished side of the individualism coin we could either try to help clients see the other (brighter) side or examine the ideas standing as alternatives to individualism (for example, communitarianism). Rather than refram- ing individualism for clients, we have in our therapeutic work been exploring ways to counter the shadowy side of the confidential- individual construct by working to promote a greater sense of connectedness with others.

In our practice, we integrate principles and values from marriage and family therapy and social work. We work from a perspective we call community-minded family therapy (St George and Wulff, 2006; Wulff and St George, 2007). By the phrase community-minded we mean that, as we listen to the particular dilemmas our client families describe, we also are listening for clues in their stories that can help us understand how the societal grand narratives that are enveloping the therapeutic system (client and helpers) are at work. It is not just the family who has become hypnotized or pulled into an invisible but influential set of ideologies and preferred practices. As they meet, clients and therapists are operating under the influence of unspoken and unconsidered dominant ideas that permeate the worlds within which we live and work. Confidentiality, as constructed and practised, is an example of one of those ideas and practices derived from the grand narrative of individualism and independence.

Therefore, when we work from a community-minded family therapy perspective we are (1) identifying grand narratives that influence us all, (2) organizing our conversations to include talk about the ways that grand narratives constrain or slow our thinking, and then (3) figuring out how we can take steps towards better managing the taken-for-granted influences in our communities that limit or hinder families.

As I (SSG) reflect on my hesitation about having Betty and Madeline meet and wonder what underpinned those feelings, I think I was concerned that I might be crossing an ethical line in the eyes of my profession and would be harming my client in doing so. Often when therapists see a potential ethical problem or breach in our thinking or behaviour, we become alarmed and consequently wary of the situation or issue. We often imagine a worst case scenario and find ourselves

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becoming very cautious and conservative, desirous of steering wide of any legal scrutiny. In a sense, the situation in question becomes abstracted into a framework of the legal and ethical versus the illegal and unethical, and the specific context and circumstances of the client’s life as a basis for decisions is largely disregarded. The situation becomes centred on the need for the therapist to be safe and secure within professional boundaries, irrespective of the consequences for the client.

Clients often indicate to us that they believe their problems are unlike those of others and they often feel ashamed and unworthy because of their perceived weakness or problem. Is a therapist’s reassurance that they are not alone, not a failure, and not hopeless robust enough to counteract their sense of isolation? Betty, for example, was convinced that she would never be seen as a success as a result of the daily experiences and messages that emphasized her inability to be a good mother and self-sufficient in the eyes of her helpers. She told us quite clearly, when we began working with her, that she ‘needed a village’ more than she needed therapy and parenting classes. Even though presenting problems differ and the ways that families live out similar problems differ, we are beginning to wonder if using the one client to one therapist model may unin- tentionally contribute to clients’ feelings of isolation. Failing to join together people who have commonalities in their life situations may render some possibilities of changing their lives invisible (Madigan and Epston, 1995). In a study of folk healing traditions around the world, Keeney (2007) explains that psychotherapy as practiced in the modern Western world is the youngest healing tradition. He states that as such it would do well to consider the wisdom of older healing processes; those that rely heavily on bringing the relevant community together to deal with problems posed by individuals in that commu- nity. Confidentiality came along with the professionalization of ther- apy. The emphases of professional helpers tended to discount what non-professionals had been doing. Society’s reification of profession- alism and clinical procedure tends to solidify therapy as the preferred and superior solution. Individual strength, family involvement and community support have trouble being recognized as significant contributors to health and well-being (McKnight, 1995).

In the second illustration, the supportive services that church members wanted to offer to the families were valuable. But because they were members of the laity (not professionals), their access to the client families and any knowledge about them was inconsistent with

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confidentiality standards. Even if one tried to develop formal ways to authorize such involvement through permission forms or releases, because the church people were not credentialed practitioners such authorizations were not possible. Technically, the church community and our clients should remain separate, especially because the clients’ status as clients would become known to non-professionals. Seeking client permission for such potential interactions is complicated because the therapist may be perceived as wielding power over the client by simply inquiring about this possibility – there may be a perception that the client could not refuse the offer.

In the third illustration we were not direct participants in the situation but were aware of the events through the media coverage. Conventional standards of confidentiality were implemented in the process of hand- ling each episode of abuse that was reported to the church authorities. It is our understanding that the details of the abuse were discussed with the abused individuals and their families as well as with the clergy accused of the unethical and abusive conduct. For reasons of confidenti- ality, these episodes were not made public in any way – apparently they were not even disclosed to legal authorities or ethics boards. Because this small circle of people kept the information cloistered, the public was unaware of the risk in their midst. Once the story broke into the media, questions were asked regarding the responsibility for the consequences of the subsequent abuses. The church authorities did not acknowledge the connection between the abuse reports they had dealt with and the subsequent abuses by the clergy.

Worker isolation

The above practice has also helped us reconsider the impact of this professionally constructed sense of isolation on both clients and therapists. Just as clients may feel isolation or aloneness so, too, may the therapists. They feel the legal jeopardy of failing to adhere to their professional code of ethics while being disinclined to discuss their dilemma with other professionals for fear of being judged negatively for even broaching the issue. An unfortunate by-product of holding these feelings of isolation is that they often remain hidden and unspoken. When I (SSG) kept my dilemma to myself, I was extremely restless and nervous and, unfortunately, isolated. When I did share it with my colleagues I felt liberated and relieved. Clearly, professional consultation is crucial in reducing feelings of isolation and worry, and

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also in providing new perspectives and ideas upon which to build. Here confidentiality is stretched as a concept.

The situation with the church community was especially poignant. Their offer to help was heartfelt and it must have been difficult for them to be told that their offer would be denied. Similarly, the professionals who were involved with the abusers and the abused were likely to be frustrated or restricted as much of their work was circumscribed by fears of legal action.

Teaching confidentiality

Students just becoming acquainted with their professional discipline may be especially prone to feelings of jeopardy associated with a strict mandate to adhere to the core principle of confidentiality. Students are presented with their profession’s specific code of ethics along with a categorical directive to abide by it – often without question (Reamer, 2001; Vesper and Brock, 1991). Unfortunately, confidentiality has become enveloped in a legal and political discourse that tends to stimulate a fearful compliance on the part of helpers to avoid being sued. Rather than being considered a set of behaviour and protocols that provide guidance on how to better serve clients, confidentiality is presented as a legalistic set of proscriptions designed to insulate helpers from legal consequences. Regrettably, it can lead helpers to think that being ethical involves only a strict adherence to component parts of one’s professional code of ethics instead of envisioning ethical behaviour in the therapeutic relationship as a negotiated interaction (Swim et al., 2001). In response to this fear of legal sanction, practi- tioners are advised to maintain a clear and set distance from clients – a professional boundary that accentuates separateness and isolation.

Purposeful questioning

If we, as family therapists, are prepared to engage in critical reflection and purposeful questioning of effective family therapy practice that involves deconstructing confidentiality we must be willing to ask the following question:

In my work with this family, would it be better to keep this family’s situation between just them and me or would it be better to include others?

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This is a crucial question. It opens up the possibility of including more individuals and networks of support in our efforts to be helpful. In any family therapy practice there are occasions and opportunities to work with other professionals and with others who are not profes- sionals (for example, Big Brothers and Big Sisters, volunteers in schools or in community centres, extended family members and neighbours). These persons can be very helpful in the therapeutic work we do with families. In order to address this question, we will need to discuss it with the client family. They have a vested interest in the progress of therapy and should be consulted in key therapeutic decisions. In fact, this option may not be one they are familiar with and, given the prevalence of their sense of isolation and worry about others knowing of their situation, it will be necessary to discuss with them the possible advantages and disadvantages of this idea. Perhaps the mere discussion of this might open the client to imagine the idea of not being isolated. The story of Betty and Madeline demonstrates the potential of this possibility. When we talk about discussing options with the family, we include all members – all have a voice. If the family members disagree with one another we invite them to continue to discuss the issue and come back with a family decision.

To engage in deliberate conversations with clients regarding con- fidentiality involves several elements. Firstly, one must believe that the client has the ability and security to consider this possibility in a realistic way. If a therapist does not trust the client in this way then any discussion of this nature could be very difficult. Secondly, the therapist would need to be willing to entertain all possibilities even-handedly. The therapist would need to be careful not to over-promote one choice over another. Thirdly, if the client expressed any doubts or reservations, the conversation would need to honour those ideas. This process of negotiating the conditions of therapy would allow clients to feel respected for their own ideas and create a sense of confidence that the family can organize and privilege those aspects of therapy they think are likely to be most beneficial.

Conclusion

We have found the process of revisiting confidentiality to be useful in freeing our thinking about what we do as therapists. Even important and cherished notions like confidentiality have a shadowy side that we must have the courage to reflect upon critically if we take seriously the challenge to constantly improve our abilities to help client families.

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Protecting clients from unwanted outside intrusiveness as they struggle with their life issues is a critical value that we wholeheartedly support. Exploitation is a real possibility when clients discuss their lives and vulnerabilities with others. Our discussion here is in no way an effort to undermine this important consideration. However, we have also come to understand that in attempting to reduce or eliminate exploitation confidentiality, practiced as a uniform and unwavering protocol cannot guarantee protection from exploitation. In a similar vein, Tomm (1991) has noted that not all aspects of dual relationships (for example, therapy and supervising) are bad. Indeed, the potential benefits that would accrue from culturally appropriate, community-minded, deeply-connected interrelationships are negated when, as our examples illustrate, clients are denied greater openness to engage and interact with others and with their professional helper.

In an ever-changing world context, new issues (for example, global warming, economic crises and international terrorism) constantly arise that challenge prevailing world-views as well as the current state of professional wisdom. Our effort to revisit the topic of confidentiality is only one of a growing number of professional concerns that could benefit from our critical reflection and deeper questioning. Reamer (1995) succinctly expresses this sentiment:

The bottom line for us is that social work is by definition a profession with (a) moral mission, and this obligates its members (to) continually examine the values and ethical dimensions of practice. Anything less would deprive social work’s clients and the broader society of (a) truly professional service. (p. 190)

The innovators and leaders in family therapy have advocated for a long time, novel and unconventional approaches to working with clients in order to meet the challenge of helping client families achieve success and happiness. We believe that such creativity and innovation are still worthwhile and useful if we are willing to revisit and expand our core beliefs and traditional practices.

References

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Besthorn, F. (2002) Radical environmentalism and the ecological self: rethinking the concept of self-identity for social work practice. Journal of Progressive Human Services, 13: 53–72.

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Clark, C. (2006) Against confidentiality? Privacy, safety and the public good in professional communications. Journal of Social Work, 6: 117–136.

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