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Confidentiality in Social Work Practice: Challenges and Ethical Dilemmas (Part I)

Report of a Simmons Research Study

By Emily Feaster, Wellington Johnson, Kathleen Kelps, Helena Levine, Carolyn MacDuffie, Kathleen Millstein, Anna Rubley, David Sandler, Pam Sinotte*

FOCUS Newsletter - November 1998

This is the first of two articles reporting the findings of a research project conducted at Simmons College School of Social Work. The research was conducted during the 1997-1998 academic year as part of a year long research seminar under the direction of Dr. Kathleen Millstein. (Part two was printed in the December issue of FOCUS)

Part I
When we, a group of ten second year Simmons MSW students and our professor, launched our research project to learn about the challenges and ethical dilemmas related to confidentiality confronting today’s social workers, we discovered that our research questions were indeed timely. We developed an anonymous questionnaire with two objectives. The first objective was to learn more about social workers’ beliefs, practice actions, and agency resources regarding confidentiality. The other research objective (which will be reported in Part II in the December FOCUS) was to identify the ethical dilemmas social workers face maintaining confidentiality and the ways that they handle these dilemmas. Both expected and surprising information was revealed by the data.

Research Sample
The survey was mailed to a research sample comprised of Simmons College School of Social Work alumni from the Class of ’92 and field supervisors for the 1997/1998 MSW program. Survey results were based on 152 (42% of the total mailed) valid questionnaires returned. The majority of respondents were white (94%) and female (83.6%) and the median number of years in human services was 11 to 15. Ninety-four percent of our respondents were currently employed. They worked in a diverse group of settings, including outpatient mental health clinics, general hospitals, schools, community mental health centers, and psychiatric hospitals. In addition, 2.8% of the sample worked for either the Department of Social Services or Youth Services and only 4.2% identified private practice as their primary employment. Though respondents worked with a diverse range of clients, in terms of race and age, the greatest percentage of their direct service time was spent with Caucasian clients (average percentage was 66.1) and a predominately adult population (average percentage of time was 56.9.)

Beliefs About Confidentiality
The social workers in our study were clear (strongly agreed or agreed) about their beliefs in the professional/ethical (99.2%) and legal (97.2%) obligations of a social worker to maintain confidentiality except under specific circumstances. They also believed (strongly agreed and agreed) that confidentiality is necessary for the therapeutic relationship. However, many more social workers strongly agreed that confidentiality is necessary for the therapeutic relationship (73.5%) than strongly agreed that clients expect confidentiality (48.3%). These findings are interesting in that they suggest that workers believe that clients do not have high expectations that their confidentiality in the therapeutic relationship will be maintained.

There was somewhat less certainty among the social workers about whether they believed that Massachusetts and Federal courts must respect the confidentiality of communications between social workers and clients. We wondered if these findings were more a reflection of knowledge about privilege laws than of their beliefs about the nature of state and federal responsibility. In addition, the results indicated least certainty about whether the requirements of third party payers threaten the confidentiality of the therapeutic relationship, including 11.3% of the sample that was undecided about whether third party payers threaten confidentiality.

Confidentiality and Practice
In an effort to better understand social workers’ practice actions, we asked questions about when social workers address confidentiality with clients, and how they address it. The results we obtained were both comforting and concerning.

A majority of our respondents always or frequently discuss confidentiality with their clients during the first session (85.3%), have their clients sign a release of confidential information form when client information has been requested by another agency (96%), and inform their clients about the limits to confidentiality should the client be a danger to themselves or others (94%). Almost all of our respondents inform clients verbally (95%). However, only half of our respondents always or frequently inform their clients about confidentiality in writing and an even smaller percentage (43%) inform their clients using a written form which the client has to sign.

A small but worrisome minority (10.8%) always or frequently waits for an issue to arise before informing their clients about confidentiality. If practitioners are waiting to inform clients about limits to confidentiality until an issue arises, there is an increased chance of ethical dilemmas arising. The delay could mean that the client has been sharing information without awareness that there are inherent limits to confidentiality. And while only 2% of our respondents seldom or never get clients to sign a release of confidential information form when another agency has requested client information, this percentage is alarming since there are legal implications and the potential for infringement of client rights.

Overall, the actions that social workers reported when addressing confidentiality with their clients demonstrate that there is a fundamental respect for confidentiality within the client/practitioner relationship. However there still appears to be a gap between theory and practice. Though verbal discussion is valuable, most current wisdom suggests the importance of having clients receive written material about limits to confidentiality, which they sign.

Agency Resources to Address Confidentiality
The study also looked at the agency resources available to social workers to help them address confidentiality concerns. The primary resource available in many of the agencies was policies (85%), most of them (87%) written. Interestingly, agency policies were more likely to address confidentiality issues spelled out in the law, such as release of information to outsiders (92%), duty to warn (91%), mandated reporting (89%), and access to client information (76%) and, in contrast, much less likely to address other issues such as discussion of case material in case conferences (44%), in supervision (39%), or in other forums with workers within the agency (62%). Seventy percent of the policies addressed release of information and/or records to insurers. And 31% of the policies included content on client computer records It would appear to us that agency policies reiterate what is already stated in the law, and do not provide workers with as much guidance in other "grayer” areas.

Despite this possible weakness, 75% of respondents were satisfied with their agency’s policies on confidentiality and felt that they adequately described clients’ rights and workers’ responsibilities. Of those who were unsatisfied, several identified the need for policy statements written for clients to contain information about an insurer’s access to their records.

Other resources available to social workers in agencies were supervision, in-service trainings and ethics committees.


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