In recent years, an increasing amount of attention has been devoted to the matter of confidentiality in mental health practice (e.g., Jagim, Wittman, & Noll, 1978; Kandler, 1977; Shah, 1970; Siegel, 1976). Confidentiality is often discussed within a broader framework, which subsumes issues of informed consent (Noll, 1974, 1976), privilege (Jagim et al., 1978; Shah, 1969; Slovenko, 1966; Suarez & Balcanoff, 1966), privacy (Siegel, 1979), legal matters (Stone, 1976; Szasz, 1963), ethical concerns (American Psychological Association, 1977a; Halleck, 1971; Perlman, 1977; Redlich & Mollica, 1976), and matters pertaining to the psychotherapeutic relationship (Jagim et al., 1978).
According to Siegel (1979), "Confidentiality involves professional ethics rather than any legalism and indicates an explicit promise or contract to reveal nothing about an individual except under conditions agreed to by the source or subject" (p. 251).
Shah (1970) defined confidentiality as "an ethic that protects the client from unauthorized disclosure of information about the client by the therapist without the client's permission, except in unusual circumstances" (p. 159).
As Siegel (1979) points out, there is a "long and complicated history" to matters of confidentiality. The complex nature of the issue prompted the APA to create the Task Force on Privacy and Confidentiality (Note 1). Although definitions of confidentiality can overlap to some extent (cf. Jagim et al., 1978; Siegel, 1979), the practical implementation of the concept is a matter of controversy. There appear to be two major postures on the issue: (a) the "absolute" position, which maintains that therapists not break confidentiality under any circumstances (e.g., Hollender, 1965; Siegel, 1976; Slawson, 1969; Szasz, 1969), and (b) the "relative" position, the more traditional of the two, which allows the therapist some circumstantial flexibility (e.g., Shah, 1970). The "relative" position recently received support in a survey finding that "over half of the respondents indicated that they would break confidentiality under certain circumstances" (Jagim et al., 1978, p. 463).
Guidelines on confidentiality are noted in the APA's 1977b Standards for Providers of Psychological Services, which states, in part:
The psychologist shall not release confidential information, except with the written consent of the user directly involved or his or her legal representative. Even after the consent has been obtained for release, the psychologist should clearly identify such information as confidential to the recipient of the information. If directed otherwise by statute or relations with the force of law or by court order, the psychologist shall seek a resolution to the conflict that is both ethically and legally feasible and appropriate. Users shall be informed in advance of any limits in the setting for maintenance of confidentiality of psychological information. (p.9)The APA, in a more recent statement ("Latest Changes in the Ethics Code," 1979), has proposed a partial revision to Principle 5 (Confidentiality) of the Ethical Standards of Psychologists (American Psychological Association, 1977a. The initial section of Principle 5 states that:
Psychologists have a primary obligation to respect the confidentiality of information obtained from a person in the course of teaching, practice, and research. They reveal such information to others only with the consent of the person or the person's legal representative, except in those unusual circumstances in which not to do so would result in clear and imminent danger to the person or to others. Psychologists inform their clients of the limits of confidentiality. (p. 17)This position is more closely aligned with the "relative" position (cf. the "absolute" position), although it further delimits the conditions under which confidentiality might be waived. These conditions are, in part, the result of the Tarasoff case l as well as other more specifically legal statutes and considerations (e.g., Pub. L. N. 93576, the Privacy Act of 1974).
The APA standards apply uniformly to psychologists and to other providers of psychological services. The principles of and guidelines for confidentiality are presumably designed to be broad enough for application to all general confidentiality issues, as well as to contain sufficient specificity so as to assist in the resolution of more unusual situations. A central thesis of the authors is that the APA's Standards for Providers of Psychological Services and Ethics Code do not, in fact, provide sufficiently clear resolutions for some situations faced by rural CMH psychologists. If one strictly adheres to these APA guidelines, potential conflicts exist for the rural community mental health practitioner given the nature of the rural community systems.
There is little disagreement that rural areas generally differ from nonrural locations (e.g., Bentz, Hollister, Edgerton, Miller, & Aponte, 1973; Jones, Wagenfeld, & Robin, 1976). Rural mental health programs have been described as different in major ways from urban and suburban programs (Daniels, 1967; Eisdorfer, Altrocchi, & Young, 1968; Huessey, 1972; Jones, Robin, & Wagenfeld, 1974; Wedel, 1969). Berry and Davis (1978), in summarizing rural-urban differences, described rural community mental health centers as "ideological misfits."
Just as various authors (e.g., Berry & Davis, 1978; Jones et al., 1976) maintain that it is inappropriate to apply uniformly an urban model of mental health service delivery to rural areas, one of the authors' contentions is that in some cases it may be equally inappropriate to apply aspects of the confidentiality principles and guidelines (which were created primarily by urban professionals) to rural practioners.
The thrust of this article is to review and discuss issues,
problems, and systems variables predominantly related to confidentiality
issues unique to rural settings. Also, rural confidentiality situations
which may conflict overtly with established professional standards are
delineated. These topics and others are addressed in a framework which
includes: (1) consumer concerns, (b) inter-agency issues, (c) intra-agency
conflicts, (d) the rural professional's dilemma, and (e) suggestions which
may help reduce the frequency and intensity of such dilemmas.
Morrison (1979) states that "Mental health agencies can be much more effective when there is full realization that a major concern of rural people when they seek help is confidentiality" (p. 18). Also, a general hesitancy to go to the Community Mental Health Center (CMHC) is frequently noted in rural areas (Angerman, Note 2; Parrott & Sebastian, Note 3). This hesitancy might be accounted for, in part, by a variety of factors related to confidentiality.
In discussing unique aspects of the rural setting, Jeffrey and Reeve (1978) comment that:
The ability to maintain confidentiality is limited by the physical and social nature of the community. In most rural areas, because of the limited number of professional persons, office space is at a premium. Initially, many centers have had to resort to sharing space with other agencies . . . it does create problems of confidentiality. (p. 58)The issue of visibility is a special rural problem. Berry and Davis (1978) state that:
All psychiatric practitioners desire to give assurance of confidentiality to clients, but the issue of visibility in a rural area is a major problem. Because of the smaller number of persons in rural areas, all or most of the people have access to only one mental health center. In small towns, people know quite well what others are doing and there is a high probability that a person visiting the center will be recognized and talked about by acquaintances. (pp. 675-676) The issue of stigmatization enters heavily in the rural setting. Shane and Seibert (Note 4), in discussing rural experiences of stigmatization, state that "Many people in the. . . area saw the center as a place to go if you were 'crazy.'" (p. 4)Rural dwellers in particular appear to have a fear of being identified and labeled as mentally ill. The stigma of being a "mental patient" in a rural area also has been noted by DeRita (1978) as a difficult one, both for the mental health worker and the rural consumer. Whereas the urban client usually has the "luxury" of anonymity, the rural client often faces the problem of local visibility with a result ant higher probability for being identified as a "mental patient."
The issue of visibility is directly related to one of the rural community's most efficient methods of communication, the word-of-mouth net work. Since many rural areas often rely on a sole weekly newspaper, the word-of-mouth network is frequently employed for communication purposes. This well-known medium has its advantages and disadvantages. One advantage in the rural setting is its use for rapid information transmission. One potential disadvantage, however, is its use for "community discussion" (viz., gossip). While few can escape being the subject of community discussion in the rural setting, the mental health client becomes a particularly vulnerable subject for such, once identified as a mental health consumer. Given the rural community's frequent utilization of the word-of mouth network and its occasional proclivity toward such discussion, the mental health consumer's high visibility might account for the reluctance and hesitancy of some rural citizens to use available CMHC resources.
Even if the rural client can overcome the fear of being visibly a client and can accept the risk of being the subject of community discussion, there are additional confidentiality factors peculiar to the rural setting that may cause difficulties in the provision of mental health services. Bischoff (Note 5) contends that rural clients tend to prefer individual mental health services, and are relatively reluctant to engage in group therapy. The United States Department of Health, Education, and Welfare (1974) provides data consistent with this contention by reporting that at federally funded rural centers, individual sessions outnumber group and family sessions by a ratio of 6 to 1, while the ratio at part-rural centers is 5 to 1, and at nonrural centers, 4 to 1. Concerns over confidentiality may, in fact, be a causative factor in this instance. However, further research would be helpful in understanding these data, given that possible alternative explanations exist.
Thus, the issues of visibility, stigmatization, and social/physical
factors in the rural community tend to interact with confidentiality matters
in this setting. Rural CMHC clients fear that their status in the community
will be adversely affected by association with the CMHC. It should be noted
that the literature emphasizes the clients' fears in regard to their community
of peers. Overlooked is the issue of clients' concerns regarding confidentiality
on the part of human service professionals. It is the contention of the
authors that some rural CMHC clients' concept of professional behavior
includes a routine and justified sharing of information among community
professionals. Under these circumstances, the informed consent forms, release
of information forms, and other appurtenances of APA confidentiality guidelines
may be perceived by clients as barriers to, not protectors of, the exercise
of their rights to CMHC services.
Client expectation of information-sharing among professionals may be given of a rural community and an accurate reflection of rural community standards. On the other hand, client expectations in this regard may be shaped by the behavior of available professional models who, in the rural setting, may more readily share information informally than do their counterparts in urban settings.
Interagency confidentiality issues pose a special problem for the rural CMHC psychologist. In many instances, these practitioners (e.g., physicians, social services, public health, and school personnel) and/or their agencies routinely expect feedback on the status of their referred clients (whether or not the client has given the mental health practitioner permission to release information). The lack of compliance on the part of the mental health worker may cause severe interagency conflict. Jeffrey and Reeve (1978) comment:
Although the right of confidentiality is becoming more accepted by rural professionals, informal channels of communication remain strong. There can be the assumption that the interagency sharing of information is not the same as divulging this information to the general public . . . Holding very strictly to the rule of confidentiality can be interpreted as questioning the integrity of the other workers. At other times, refusal to share readily information on common clients is seen as indicative of the snobbery of mental health professionals, their "ivory tower" view of problems, or their preference for psychoanalytic theory over reality. (p. 58)The existing rural human service agencies typically are staffed predominantly with locally born and raised citizens who have well established informal social and professional communication networks. As Jeffrey and Reeve (1978) point out, local practitioners do not perceive the expression of private client information to other professionals as a violation of confidentiality; they may define a violation of confidentiality solely as the expression of client information to a member of the general public. The mental health worker who fails to understand the existing nature of the rural system and adheres strictly to the espoused professional rules of
Thus, it seems probable that mental health professionals
in rural areas who are insensitive to or unaware of the prevailing local
norms regarding confidentiality run the immediate risk of professional
isolation and lack of referrals. In a larger sense, the very existence
and survival of a new CMHC in a rural area may be determined both by the
mental health practitioner's philosophical perspective on matters of confidentiality,
and by the practical stance that he/she takes on such issues with the established
Intra-agency issues of confidentiality in the rural setting can often be a source of conflict. In discussing the hiring of local citizens as CMHC staff members, Jeffrey and Reeve (1978) comment:
Staffing decisions also require careful consideration because of the issue of confidentiality . . . Certainly, there are advantages in having local persons on the staff . . . they help to provide important insights into the community. At the same time, there are serious disadvantages to having local people...If the worker is well known, there is considerable fear that information will be passed from him to others in the community. (p. 58)The hiring of local citizens for clerical or professional positions can therefore be a help or a detriment in the adherence to confidentiality principles. The applicant's understanding of and willingness to engage in ethical professional behavior is probably the major issue of importance in this regard, and can have significant consequences for client confidentiality and the success or failure of a rural CMHC.
The paraprofessional movement, which is based upon the assumption that indigenous helpers may be more helpful because they are more understanding than professionals of their clients' life circumstances, has different ramifications for confidentiality in a rural vs. urban setting. In a city, paraprofessionals would be unlikely to be familiar with a client or to interact on a day-to-day basis outside the agency, but in a rural setting, such relationships may well be the norm.
The use of volunteers and indigenous paraprofessionals is reported to have a variety of effects on confidentiality matters. Segal (1973) discusses the value of these helpers as care providers in rural areas. Berry and Davis (1978) encourage the use of local volunteers in the rural setting.
A very positive experience with the use of rural volunteers is reported by Shane and Siebert (Note 4):
They are carefully chosen and impressed with the importance of confidentiality. They do not have access to the files of the clients and know only the names of the persons who come for service. We have had virtually no negative feedback from the community regarding confidentiality issues, although there was some fear that we might in the beginning. (p. 5)
Jones et al. (1976) consider the use of local paraprofessionals an innovative characteristic in rural community mental health, yet tend to view their value as both a strength and a weakness. According to these authors, the strength is that they "go a long way toward putting 'community' into mental health" (p. 178). They feel, however, it is possible that the lack of formal training reduces their utility, especially when the risk of breaching client confidentiality is considered.
Other authors take a more pessimistic view. Wedel (1969) and Berry and Davis (1978) suggest that there might be a great deal of resistance among rural residents to sharing problems with their own acquaintances. Jeffrey and Reeve (1978) state that "In any large scale use of volunteers, there clearly would be significant problems in protecting the privacy of clients" (p. 59). The utility of paraprofessionals, as it pertains to ensuring client confidentiality, has generated mixed opinions. Perhaps the matter would be resolved best empirically.
Another area of concern is the use of local college students, who may be fulfilling practicum requirements at the CMHC. There may be difficulties inherent in the student's attempt to provide the professor and/or class members with a comprehensive description of the client(s) with whom the student is working without diminishing confidentiality with respect to the client's identity. This is most likely to occur in rural mental health settings where only a general description of an individual may in fact be sufficient to cue another as to the identity of the client and thus violate inadvertently the confidentiality principle.
A final area of intra-agency concern deals with the provision
of mental health services to CMHC staff members and/or their families.
Whereas urban CMHCs typically have reciprocal agreements with neighboring
centers to provide services for staff members, rural centers rarely have
such an opportunity due to lack of nearby professional services. The provision
of services within a rural CMHC may constitute special circumstances leading
to unique problems of confidentiality (Solomon, 1979).
Establishing positive professional relationships and cultivating referral sources is not easy in the rural environment. Webster (Note 6), in commenting on rural settings, states that the CMHC has been introduced into an environment that views mental health professionals as outsiders and where there is a resistance to outside help. Perlmutter (1979) echoes this view: "First, the ideological orientations of the rural catchment areas are critical as they provide an inhospitable and often hostile environment for the centers" (p. 61). Although the mental health professional may enter the rural system with the best of intentions, it is not unusual to encounter hostile oppositionalism or blatant negativism from established community practitioners (Libo & Griffith, 1966).
Community conservatism is a frequently noted feature
of rural areas (Hoxworth, 1978), as is skepticism and apprehension about
new mental health services (Leunes, 1975). Resistance to mental health
may exist for a number of reasons: The perception that mental health professionals
are invading one's domain (Bischoff, Note 5), the fear of the unknown (Butteweg,
1974), the perceived threat that a new CMHC would upset the local human
service delivery system (Parrott & Sebastian, Note 3; Shane & Seibert,
Note 4), the resentment of mental health personnel by people in the community
who are reluctant to relinquish their therapist roles (Berry & Davis,
1978), and the fear that the mental health professional will not be appreciative
of the existing caregivers (Thompson & Bell, 1969). Clearly then, the
mental health professional's entry into the rural system may not be a very
Bischoff (Note 5) discusses the urban to rural transition and the change in prevailing community values that face the mental health worker, which may cause the mental health professional to confront profound ethical dilemmas. One such conflict could conceivably be the result of vagueness in the APA's proposed revisions to the Ethical Standards of Psychologists (cf. Latest Changes in Ethics Code, 1979). Principle 3 (Moral and Legal Standards) states, in part:
Regarding their own behavior, psychologists are sensitive to the prevailing community standards and of the possible impact upon the quality of professional services provided by their conformity to or deviation from these standards. Psychologists are also aware of the possible impact of their public behavior upon the ability of colleagues to perform their professional duties. (p. 16)Although Principle 3 might be intended to serve as a guideline for psychologists' personal, public, or nonprofessional behavior, it nonetheless refers to "their own behavior", a statement which could be interpreted as referring to all behavior, professional behavior included. Assuming this to be true, then, the key phrase for rural community mental health in Principle 3 is "prevailing community standards." Consider the proposed revisions to Principle 5 (Confidentiality), as well as section 2.3.5 of the Standards for Providers of Psychological Services (American Psychological Association 1977b). The limits of confidentiality are specific. However, how is the rural community mental health professional to reconcile the specificity of confidentiality limitations in an area whose "prevailing community standards" are less stringent than those of the APA?
Consider, for example, a situation in which a rural area has but one physician. The CMHC receives a referral from the physician to provide counseling for one of his/her patients. The psychologist assigned to the case casually but thoroughly explains to the physician the content of Principle 6, section b (Welfare of the Consumer) of the Ethical Standards. In other words, the psychologist, being requested to provide services at the request of a third party (the physician), "assumes the responsibility of clarifying the nature of the relationships to all parties concerned" (Latest Changes in Ethics Code, 1979, p. 17).
The patient begins therapy with the psychologist, and is now both a client of the CMHC and a patient of the physician. A few weeks later the physician makes a routine follow-up call to the psychologist to check on the patient's status. This procedure is often typical among service professionals in rural areas, and is considered to be routine practice, viz., "prevailing community standards." The psychologist has no written authorization for the release of information, and informs the physician of this. The physician gently states that he/she is not interested in the specifics of the therapeutic endeavor, just whether or not the patient is keeping appointments and making any progress. The psychologist reiterates his/her position, and politely refuses to comment. The physician is angered over the psychologist's "lack of cooperation," becomes antagonistic toward the psychologist (and perhaps even the CMHC), and refuses to refer any more patients for CMHC services. In this example, the psychologist is following the Confidentiality Principle thoroughly, yet may be considered "guilty" of not being "sensitive" to the prevailing community standards. Are the client's interests being served best? Has the psychologist, by adhering utterly to Principle 5, done what is best for the client, for the collaborative relationship between the CMHC and the only physician in the area, and for the community in general?
Balancing professional standards of confidentiality with the demands of a rural system is a difficult task. Perlman (1977) comments: "In any type of community mental health activity....judgments can become muddled by multiple loyalties and conflicting demands" (p. 46).
The reality of the rural system is that personal trust is the key variable. Berry and Davis (1978) echo this point: "Mental health workers discover that they must play the game the rural community's way, and that it takes awhile, as outsiders, to gain the trust of rural people" (p. 675). Jeffrey and Reeve (1978) elaborate further:
A person can be seen as a useful professional only if he can be seen as a trustworthy individual; in a rural setting, personal trust supersedes (sic) issues of competence. The mental health professional may have valuable insights to provide. . .but these insights seem to be rejected unless personal trust has been established. (p. 57)It seems mandatory that trust be the initial objective that a psychologist needs to achieve in the rural setting. Trust is necessary in the client-therapist relationship, as well as in consulting relationships with community professionals. It is ironical, and often distressing, to find that in some rural situations, the very trust which the psychologist has attempted to promote through rigorous confidentiality procedures can serve as the downfall in consulting, as well as other relationships with professionals. Perhaps, then, it should be considered that in the rural setting, at least two standards of confidentiality about clients hold, one for the professionals and at least one for the public. To be perceived as trustworthy and competent by some rural clients, the psychologist must keep client confidences safe from public scrutiny but open to the shared information network of human service professionals. The potential for role conflict in such circumstances is great, especially where financial benefits, such as workman's compensation or SSI, are involved. Clients may want and need confidential services, yet they may not wish to concern themselves with the "bureaucratic red tape" which accompanies formal confidentiality procedures. Of course, there are likely to be other clients who will demand rigorous adherence to absolute confidentiality.
Thus, the rural system appears to be a unique subject for certain issues of confidentiality. Resolutions to these problems are not simple. Morrison (1979), in taking an absolute position on confidentiality, maintains that "most people want high quality confidential direct services and could care less whether or not agencies get along" (p. 18, italics in original). Other authors (e.g., Jeffrey & Reeve, 1978; Solomon, 1979) imply that although the absolute position may be desirable, the relative posture may be more realistic, at least initially. While most people may not care or even know whether agencies get along, it is not the general public who always wields the political and bureaucratic power which maintains the CMHC. An alternative approach would be to reach some compromise between the ideal state of affairs presented by the APA confidentiality guidelines and the realities of prevailing standards in various rural communities.
Some would argue that consent and release forms are inappropriate for many rural areas and that some rural physicians (and other human set vice professionals) would be intransigent in their opposition to greater limits on confidentiality. Others would take a far less extreme position. This is an issue which clearly merits further study.
The professional psychologist ultimately makes choices when faced with these dilemmas; the particular choices exercised lead to certain out comes which affect the client, agencies involved, and the psychologist. Within the absolute position, a resolution of conflict and dilemma may be possible by using consent for information release forms. In some instances, a consequence of this step would be the facilitation of information exchange within the system of services via formal procedures. A positive consequence might be acceptance and trust of the CMHC by other agencies, the general public, and clients. However, some agency personnel or local professionals might resent the requirement to adhere to formal procedure, and might refuse to cooperate fully with the CMHC in service provision. A negative consequence may be that for some clients there may be resulting inhibition of self-disclosure about personal concerns in therapy. A second negative consequence would be the hesitation of some rural clients to utilize CMHC services because they would perceive excessive paperwork (e.g., release forms, waivers, etc.) as a prerequisite to services.
Within the relative position, careful assessment of prevailing community standards can be used as an appropriate guideline. A positive consequence of this position may be that staying within prevailing community standards will result in greater acceptance of mental health personnel and services by local professionals. A positive consequence for the client is the assurance of continuous information sharing by agencies. On the other hand, it is possible that some clients will become verbally inhibited if they cannot be assured of absolute confidentiality. A final negative consequence may be the legal and ethical risk incurred by the mental health professional who deviates from the absolute position.
Potential solutions to the rural confidentiality dilemmas are offered. One possibility is for CMCHs to sponsor confidentiality workshops for community professionals where the various human service agencies congregate and share their personal views, as well as those mandated by their respective agencies and professional associations. Increased awareness of state and federal guidelines, both for professionals and the public, would be the goal. The educational process would need to include the patient population as well, and could have the positive effect of leading to greater awareness of personal rights and a greater appreciation for the bureaucratic procedures designed to protect those rights.
A second possibility is for the mental health professional, upon his/her entry into the rural system, to meet individually with other human service providers and to present his/her views on confidentiality, whether relative or absolute, at the onset. Another tactic is for the mental health professional to maintain an initial stance of great flexibility, while later, after the interagency contact has solidified, undertaking an informal shaping procedure designed to educate community caregivers as to what constitutes an appropriate or inappropriate request for information, and the procedures necessary for obtaining such. This implies an initial relative stance, with an ultimate goal for achieving a climate in which the absolute procedure prevails.
All of these alternatives have both short- and long-range consequences for those involved. The consequences of each position may be determined empirically. However, judgments as to whether these consequences are positive or negative involve values. Just as the urban condition does not necessarily describe the rural setting, the particular values of one rural community may not be generalizable to other communities.
Jeffrey and Reeve (1978) conclude:
Thus the rural setting is not an easy one in which to develop mental health services. The system is highly complex, with extensive interconnecting relationships, formal and informal lines of communication, and well established rules of appropriate behavior. Confidentiality is important . . . but it is difficult to provide because of the ease with which information is circulated. The staff is constantly balancing alternatives since in addition to its clinical consequences, each decision may have ramifications throughout the system. (p. 61)The complexities of confidentiality issues in rural community mental health settings provide a challenge not only to the individual practitioner but to the profession as a whole. The American Psychological Association might attend to these complexities so as to provide more specific guidelines in the resolution of such issues, or at least provide clear interpretations of Principle 3 (i.e., whether professional behavior is included in reference to the "prevailing community standards" statement).
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Issues relating to confidentiality are becoming increasingly critical in the mental health field. Although guide lines for and principles of confidentiality abound, problematic situations frequently arise in which the ethical standards are not sufficiently specific so as to provide an acceptable resolution. The authors maintain that the rural community mental health center and its staff are particularly vulnerable to confidentiality dilemmas in which the established professional guidelines tend to place the rural practitioner in opposition to prevailing rural community standards. A review of rural issues, problems, and systems variables as they relate to matters of confidentiality is presented and discussed.
1 Tarasoff vs. Regents of University of California. 13, C. 3d 177, 118 Cal. Rptr. 129, 529 P. 2d 553, vacated. 131 Cal. Rptr. 14, 551 P. 2d 334 (1976).
(Original journal pages 17-37)