Confidentiality Limits in Psychotherapy:
Ethics Checklists for Mental Health Professionals
Mary Alice Fisher, Ph.D.
American Psychological Association, March 2016
“Fisher provides a much-needed desk manual for practicing clinicians, whether they be seasoned clinicians or therapists in training. In checklist format, she uses her ethical practice model to offer mental health professionals a step-by-step process for threading their way through the maze of ethical and legal responsibilities that have made the area of therapeutic confidentiality so complex in theory and so confusing in practice. Therapists should find this a useful tool for learning how to take an ethics-first approach to protecting their patients’ confidentiality rights, even when their confidences are not always protectable.”
—Richard E. Redding, JD, PhD, Vice Chancellor for Graduate Education and Wang-Fradkin Professor of Law and Psychology, Chapman University, Orange, CA
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“Can therapists keep their patients’ secrets? Psychotherapists are careful to safeguard information about their clients, but in some instances, they may be legally or otherwise compelled to disclose information, even without client consent. This confidentiality manual walks readers through this complex topic, using Fisher’s easy-to-follow six-step ethical practice model. The checklist format enables therapists to inform themselves systematically about ethical options and relevant state and federal laws, so they can decide if, when, and in what respects they will limit their protection of clients’ confidences—and then discuss these limits with prospective clients. The chapters and case studies are full of useful information, making this the most convenient guide available to therapists on the topic. Resource lists and appendices for further reading are included. An essential tool—not only for practicing therapists but also for peer consultants, ethics professors in clinical training programs, and supervisors of students on internships and practica—this handy reference belongs on every practitioner’s desktop.
“Fisher has constructed a very useful format for clinicians to learn psychotherapy confidentiality ethics. Her ethical practice model guides clinicians through the sticky wicket of keeping confidences in the psychotherapy process. She has also created a handy checklist and reference manual for clinicians to use as they confront confidentiality concerns in their daily practice.”
—Thomas J. DeMaio, PhD, independent practice, Charlottesville, VA
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MANUAL’S CHECKLISTS IDEAL FOR PEER DISCUSSION – Review By James K. Luiselli, Ed.D., ABPP, BCBA-D
Psychologists, counselors and other mental health professionals must adhere to codes of ethics in delivering therapeutic services. Ethical principles dictate practice standards intended to protect the welfare of service-recipients and society at large.
This compact manual (79 text pages) uses a checklist format to help mental health professionals deal with practical challenges and resolve ethical-legal dilemmas involving confidentiality. Author May Alice Fisher describes the manual “as a handy desktop resource for practicing clinicians and as a teaching tool for professors, supervisors, and workshop leaders.” The basis of the manual is an ethical practice model that applies to all of the services provided by mental health professionals regardless of theoretical orientation and setting. The key principles of the model are to put the ethical rules first, learn the relevant laws and avoid ethical-legal confusion.
Fisher presents six ethics checklists, each one contained in a separate chapter. The checklists cover the following areas: (a) preparing to protect confidentiality rights, (b) telling clients about confidentiality limits, (c) obtaining informed consent, (d) responding to involuntary disclosures, (e) avoiding breaches of confidentiality, and (f) educating professionals and the public. Each chapter-checklist follows the same structure of multiple one-sentence guidelines such as “Establish and maintain protective policies and procedures in an office, institution, or agency.” The guidelines are further delineated with several simply stated instructions, for example, “Write clear policies that describe the behavior I expect about confidentiality,” and “In all circumstances, disclose only the minimum information necessary.”
A second element of each chapter-checklist is a list of resources that apply to the respective guidelines and instructions. The resources are comprised of publication references Web site links, and information Fisher prepared in several helpful appendices. Finally, all of the chapter checklists conclude with discussion pages which highlight and further advance practice considerations. Also featured is a brief case illustration that is intended to elucidate complex matters of confidentiality by “taking the client’s perspective.”
The manual is nicely packaged, spiral-bound, and in the best tradition of a desk reference. It is a useful guide for safeguarding confidentiality during all phases of therapy, avoiding common pitfalls and protecting clients and professionals. However, simply reading an ethics-focused guidebook like this one is not enough. On this note, Fisher advises that although professionals will use the manual independently, “You are encouraged to consider working your way through it along with others, as a group, if you are able.” Indeed, discussing and reviewing this manual with peers is perhaps the best way to put these valuable checklists into action. The same can be said for using the manual as text or curriculum in graduate school courses, training seminars and continuing education workshops.
Review March 2017 New England Psychologist, page 5
By James K. Luiselli, Ed.D., ABPP, BCBA-D, is Chief Clinical Officer, Clinical Solutions, Inc. and North East Educational and Developmental Support Center, Tewksbury, Mass.
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CAN YOU KEEP A SECRET? “One might say that confidentiality is the hallmark of psychotherapy. It is an environment that allows individuals to discuss and explore painful experiences, unconscious desires, and maladaptive behaviors. The security of knowing “what is said in therapy stays in therapy” can be reassuring and foster healing. However, as pointed out in Mary Alice Fisher’s book, Confidentiality Limits in Psychotherapy, the process behind maintaining a client’s information can be ambiguous if psychotherapists are not knowledgeable about their profession’s ethics code, applicable state and federal laws, and types of disclosure (i.e., voluntary, legally required disclosure, and legally allowed). Obviously, this can have unintended and unfortunate consequences for both the patient and clinician.
“Fisher’s book is a practical desktop resource that seasoned and novice clinicians, as well as students-in-training, can utilize. The content contained in this book is a reminder to some, and an introduction to others, about the importance of knowing one’s ethical and legal obligations. Fisher describes the pitfalls that can ensue when clinicians haphazardly place limits on confidentiality. Through the six-step ethical decision-making model, Fisher explores the advantages and disadvantages of adhering to ethical and legal obligations versus refusing to comply in an attempt to protect a client’s confidentiality.
“Throughout the manual, Fisher emphasizes a “positive ethics” approach and takes a proactive stance to the issue of confidentiality by advocating the necessity for clear communication during the initial intake session. In addition to informing patients about instances by which confidentiality can be breached, Fisher admonishes the clinician to have an honest conversation about informed consent as it applies to confidentiality, specifically voluntary and legally required disclosures. Similarly, she encourages clinicians to refrain from using “canned” consent forms and argues the importance of tailoring forms to the specification of the request.
“The tone of the book is quite refreshing. It avoids psychological and legal jargon when possible and speaks to the reader in a way that is reassuring but honest. A strength of the book is that it takes a preventative approach and clearly explains how to avoid situations like confidentiality breaches, reviews the importance of “true” informed consent for releasing information about a client or patient, and provides guidance on how to educate patients, clinicians and the public about the importance of confidentiality. This is a lot to accomplish in such as short book. Coming in at 130 pages total, including references and seven appendices, a lot of ground is covered. And as for the appendices, they make up a third of the entire book; some could argue that they are the most useful aspect of the book. The topics include online sources for professional ethics, definitions, laws and regulations affecting confidentiality, example handouts, and ethical and legal responsibilities. In all fairness, there are other books on the market that cover confidentiality (Barnett & Johnson, 2015; Nagy, 2011; Sonne, 2012) but none are as focused and detailed on this specific topic as Confidentiality Limits in Psychotherapy.
“In summary, Fisher arms readers with an arsenal of resources to guide their decision-making process. Each chapter is inclusive of checklists, discussions, and realistic vignettes, designed to reinforce learning and foster critical thinking about foreseeable ethical dilemmas. Unlike most manuals, this book is an easy read and provides the reader with everything the busy clinician needs to avoid ethical and legal complications related to client confidentiality. This book is a must-have desktop resource for all mental health professionals. It will be particularly useful for training new mental health professionals with regard to protecting the information of those they will soon serve.
Disclaimer: The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of U. S. Army Regional Health Command-Central, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army and Department of Defense, or the U.S. Government.
- Barnett, J. E., & Johnson, W. B. (2015). Ethics desk reference for counselors (2nd ed.). Alexandria, VA: American Counseling Association. http://dx.doi.org/10.1002/9781119221555 
- Nagy, T. F. (2011). Essential ethics for psychologists: A primer for understanding and mastering core issues. Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/12345-000 
- Sonne, J. L. (2012). PsycEssentials: A pocket resource for mental health practitioners. Washington, DC: American Psychological Association.
–Bret A. Moore & Shamecca Scott —
— Online at PsychCritiques: http://psycnet.apa.org/critiques/61/32/1.html ]
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The Ethics of Conditional Confidentiality:
A Practice Model for Mental Health Professionals
Mary Alice Fisher, Ph.D.
Oxford University Press, January 2013
“No one has written more thoughtfully, knowledgeably, and realistically about confidentiality than Mary Alice Fisher. She has rescued the ethics of confidentiality after they have been all but hopelessly confused with legal mandates, risk management, and impractical guidelines. This book is unsurpassed in helping us think through the hard questions we encounter in practice, work through conflicting values, and find creative ways to meet our responsibilities. It deserves to land on the required reading lists in all graduate programs and find its way into the libraries of all clinicians, from those just starting out to the most experienced.”
— Ken Pope, Ph.D., ABPP
“Dr. Fisher has created a comprehensive guide to confidentiality for mental health professionals in a highly digestible and readily useable form. Practitioners and students alike will quite easily find answers to their questions on best practices and management of confidential material. I recommend this as interesting reading and an important practical reference work.”
— Gerald P. Koocher, Associate Provost and Professor of Psychology, Simmons College
“A Road Map for Finding Our Way Through the Confidentiality Labyrinth”
[Concluding Remarks] “This book is an outstanding resource for mental health professionals in all areas of professional practice. It is clearly written, easily understood, very practical in its focus, and actually, a very interesting and engaging read. In keeping with a focus on prevention and on avoiding ethical missteps, I recommend that every mental health clinician read and regularly use this excellent book. Doing so is in keeping with the general principles of the American Psychological Association (2010) ethics code that guide us to aspire to the highest possible levels of competence and conduct in our professional roles. The Ethics of Conditional Confidentiality is an outstanding resource that can help us make great strides toward achieving these goals.” (For complete review see PsycCRITIQUES-Contemporary Psychology: APA Review of Books. Vol 58(34), 2013, doi: 10.1037/a0033222 )
—Jeffrey E. Barnett, Psy.D., ABPP, Loyola University
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“With the constant changes in ethical and legal circles regarding many areas of patient care, frequent updates are vital to give practitioners an understanding of the history of such issues, as well as the current climate and anticipated future directions. This work is ambitious in its attempt to pull this off, and it does a remarkably decent job of meeting the author’s goals. Challenging concepts are discussed thoroughly, with a practical bent relevant for mental health providers across specialty or training. What may be the most useful is the last chapter, Ethics-Based Staff Training About Confidentiality. This work should find a place on the shelf of any provider practicing in healthcare.”
— DOODY’S [Reviewer: Steven T. Herron, MD (University of Arizona Health Sciences Center)]
Elizabeth Shaw in the journal, “Psychotherapy in Australia”
“Confidentiality: Not As Straightforward As We Would Have Thought”
“In 2010 I wrote about the limitations of confidentiality in contemporary practice for this column. I would have found Fisher’s exhaustive exploration of the complexity and nuance of confidentiality invaluable at the time. It makes fascinating reading by turns; unnerving in relation to the numerous legal and ethical aspects we need to be abreast of, and reassuring in making these aspects so clear accompanied by practical recommendations to assist with compliance. . . .”
“Fisher challenges us to have more conversations about confidentiality. She argues that anxiety about it can lead to confidentiality becoming all too confidential! For those who have determined to take an ‘absolutist’ position in relation to confidentiality there may be the perception that there is less need to discuss their position at the ‘front end’ as their position never varies. However, there are many more issues that will emerge later, both legally and ethically, in taking such a stance. They will need support in keeping their promise, as well as manage the consequences of how they intend to behave. At the other polarity, those who take a ‘conditional confidentiality’ position (and isn’t it interesting to consider we might have choices?) will need more support at the ‘front end’ in deciding how to plan the work and what to say to clients at the outset. In each case, as well as the times when we might all make exceptions to our usual rules, we need the support of good colleagues who can challenge us on when the departure can be ethically and professionally defended, and when we have gone off on a morally questionable tangent, even when trying to do our best. . . . .”
“Mary Alice Fisher’s book is comprehensive and thought provoking. However, like many books on ethical practice, therapists could walk past it with the view “I have my position on that completely sorted”. . . . Personally, I find issues surrounding confidentiality remarkably challenging, We need to support each other by discussing these sorts of challenges and how we can create ways to work well together, but not at the expense of our clients, and not by putting ourselves at risk. Therefore this is the sort of book really worth dipping into, and bringing to the attention of colleagues.”
— Shaw, Elizabeth (2013, August). “Confidentiality: Not as Straightforward As We Would Have Thought.” [From her column, “Sacred Cows and Sleeping Dogs”] Psychotherapy in Australia, 19 (4) pp. 65-66.
Ken Pope (recommendation on his list-serve):
I read a new book that I believe will be useful to virtually all clinical and forensic professionals . . . The book is a wonderful and badly-needed *practical* guide through the tangle of ethical standards, clinical considerations, statutes, case law, administrative requirements, and other factors affecting our individual decisions about confidentiality in regard to each unique patient.”
“I believe that no one has written more thoughtfully, knowledgeably, and realistically about confidentiality than Dr. Fisher. In her prior works and especially in this excellent book, she has rescued the ethics of confidentiality after they have been all but hopelessly confused with legal mandates (including HIPAA), risk management, and impractical guidelines. She also shows paths toward creating the best solutions to confidentiality dilemmas rather than–as we’re often tempted to do if we’re tired, rushed, anxious, or overwhelmed–settling for whatever seems to work. As she writes on page 121, “Ethics Codes create the ‘ethical floor’ — the minimum standards of behavior. But if therapists do no more than follow the minimum rules, they are missing the major point about confidentiality.”
“This book is unsurpassed in helping us think through the hard questions we encounter in practice, work through conflicting values, and find creative ways to meet our responsibilities.”
— Ken Pope, Ph.D., ABPP