introducing limits of confidentiality in real-life consultations: psychologist-driven or...
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Introducing Limits of Confidentiality 1
Running head: CONFIDENTIALITY IN REAL-LIFE CONSULTATIONS
Introducing Limits of Confidentiality in Real-Life Consultations: Psychologist-driven or
Client-centred?
Andrea Lamont-Mills
Steven A. Christensen
Centre for Rural and Remote Area Health
University of Southern Queensland
Introducing Limits of Confidentiality 2
Abstract
The Australian Psychological Society Code of Ethics explicitly states that clients are to be
informed about the legal limits of confidentiality prior to engaging in any psychological
relationship. Maintaining and respecting client confidentiality is also seen as a major
professional obligation. Despite this, little research has examined how limits of
confidentiality is introduced, discussed, and oriented to in real-life psychological
consultations. An initial consultation between a client and a provisionally registered
psychologist was used to explore how a psychologist and client interactively managed limits
of confidentiality. Using a discursive psychological framework, analysis revealed that while
the psychologist complied with the ethical obligation of informing the client of the limits of
confidentially before counselling began, the way in which the psychologist enacted this
restricted the client’s opportunities to ask questions or seek clarification about these limits.
Further, when the psychologist explicitly asked for client confirmation of understanding and
acceptance of these limits, what the client confirmed and accepted appears unclear. Given
that breaches of confidentiality are Registration Board matters, this lack of clarity and
limiting of client interaction is concerning.
Introducing Limits of Confidentiality 3
The Australian Psychological Society (APS) Code of Ethics (Australian Psychological
Society, 2007) and the APS Guidelines on Confidentiality (Australian Psychological Society,
1999) explicitly state that clients need to be informed about the legal limits of confidentiality
prior to engaging in any psychological relationship. The Code and Guidelines are also clear
that clients may need to be re-informed of these limits as the psychological relationship
progresses. Ethical issues, which include maintaining appropriate standards of
confidentiality, and being able to demonstrate knowledge and practice in relation to
confidentiality, are required areas of specialist knowledge for psychologists applying for
membership to the APS College of Counselling Psychologists. With regards to practice,
maintaining and respecting client confidentiality is seen as integral to successful therapy
(Crenshaw & Lichtenberg, 1993). However, how psychologists introduce and discuss the
limits of confidentiality in real-life psychological consultations has been little studied.
This is surprising given that explaining the limits of confidentiality is considered to be a
major professional obligation for psychologists (Behnke, 2005; Fisher, 2008). Failure to
explain the limits of confidentiality may be considered grounds for a Registration Board
complaint. In the United States, maintaining confidentiality is the most serious ethical
dilemma faced by psychologists (Fisher, 2008). In 2007, breaches of confidentiality were
amongst the top 5 Registration Board complaints in South Australia and Queensland (South
Australian Psychologists Registration Board, 2006-07; Psychologists Board of Queensland,
2006-07). In most other Australian States, breaches of confidentiality accounted for
approximately 5-10% of all complaints in 2007 (K. Firth personal communication, January
16th 2008; J. Garcia personal communication, January 16th 2008; J. Lu Serafin personal
communication, January 30th 2008).
Research that has considered the limits of confidentiality can broadly be grouped into four
areas. First, there is research that has examined how participants’ perceptions of disclosure is
Introducing Limits of Confidentiality 4
influenced by the amount of confidentiality information presented in a range of therapy
vignettes (Haut & Muehleman, 1986; Muehleman, Pickens, & Robinson, 1985). Results
reveal that participants’ perceptions of disclosure are not related to the amount of
confidentiality information that is presented. Second, there is research on how psychologists
deal with limits of confidentiality in practice settings. Results show that there is a large range
of self-reported practices (Baird & Rupert, 1987). Third, there is research that has explored
when it is appropriate for psychologists to breach confidentiality. Psychologists report that
intense and frequent risk behaviours that are of sufficiently long duration are deemed to be
appropriate reasons for breaching confidentiality (Rae, Sullivan, Pena Razo, George, &
Ramirez, 2002). Finally, how clients understand limits of confidentiality has also been
examined. Results indicate that while clients have a relatively clear understanding of the
general concept of confidentiality, they are less clear regarding the circumstances under
which confidentiality can be breached (Claiborn, Berberoglu, Nerison, & Somberg, 1994;
Hillerbran & Claiborn, 1988).
While the above research deals with some issues, the ability of this research to inform
actual psychological practice is limited because of the use of non-client populations,
vignettes, and self-report surveys. The use of non-client populations, in some studies, make
generalisation to client populations problematic. For example, those participants with
therapy experience may be more (or less) inclined to disclose information given their
experiences of the therapeutic process than those who do not have such experience. With
regards to vignettes, constructing vignettes that best capture the issue under examination
from a client’s perspective is recognised as a difficult task and raises questions about the
potential representativeness of vignette-based studies (Skaner, Bring, & Sterner, 2004). Self-
report surveys collect self-reported behaviours which may or may not be reflective of actual
real-life psychological practices (Crenshaw & Lichtenberg, 1993). Further, self-reports have
Introducing Limits of Confidentiality 5
the potential to produce under, and incomplete reporting that can bias results (Hillerbran &
Claiborn, 1988).
A review of the literature reveals no published research that has examined limits of
confidentiality within real-life psychological consultations. Thus, how the limits of
confidentiality is introduced, discussed, and treated by psychologist and client in real-life
consultations is unknown to the research literature. How clients and psychologists
understand the limits of confidentiality in practice is, therefore, unclear. Given this absence
and the importance placed on explaining the limits of confidentiality by the profession, the
aim of this paper was to examine this interaction within a real-life psychological
consultation.
Method
Analytic approach
The theoretical and methodological framework adopted in this paper is Discursive
Psychology (DP). DP is concerned with how people use discourse to make sense of and
account for their worlds (Potter, 1996). There are three basic premises that underpin DP. The
first premise in DP is that discourse is action-oriented (Edwards & Potter, 2005). DP sees
discourse as doing things or performing certain actions such as requests, excuses, refusals,
reformulations, and apologies, that are embedded within broader social and institutional
practices. This is in contrast to seeing discourse as reflective of abstract cognitive processes.
The interest in DP is on making explicit how psychological concepts are used in everyday
talk to perform certain actions. This means examining how psychological concepts are
displayed in talk and how they are used to do or accomplish things. In this sense,
psychological concepts get studied in talk for how they are linked to the actions that the talk
performs and how they get constituted through discursive interaction. Action is understood
through how people in the interaction respond to, accept, and reject each other’s discourse.
Introducing Limits of Confidentiality 6
The second premise is that discourse is situated in the local interaction. DP argues that
discourse is situated by way of its occasioned, institutional, and rhetorical character
(Edwards & Potter, 2005). Occasioned talk means that discourse is sequentially organised,
where what is said is understood as being in response to what was said immediately before
it. Occasioned talk is usually conditionally relevant on the immediate prior utterance;
however this does not mean that what was said before determines what will come next.
Rather, what is said next is oriented to or occasioned by what came before it rather than
being determined by it.
Institutional talk means that what occurs within a particular institutional setting (e.g.,
counselling room) may be influenced by the institutional identities (e.g., psychologist-client)
and tasks (e.g., psychological therapy) that people in the setting may adopt (Potter, 2003).
Here DP considers the way in which participants themselves orient to and make relevant
institutional identities. In DP, the institutionality of talk is not a contextual given, rather what
analysis examines is how participants themselves make relevant wider contextual concerns
in the interaction through participants’ own orientation to institutional identities and tasks.
For example, two people in a counselling room may interact as two colleagues, as employer
and employee, or as psychologist and client. It is not the context that makes the institutional
identity omnipresent, what makes identity omnipresent is how participants themselves
invoke the identities of psychologist and client (Potter). Thus what is important in DP is that
institutional identities and tasks are participants’ concerns displayed in talk. They are not
researchers’ inferences about what is occurring in the data or what they think participants’
mean.
Rhetorical talk means that talk is often designed to counter any potential or real
alternatives to what is being claimed, described, or formulated. It is also designed to counter
any attempt that may be made to discredit what was said by suggesting the talk was partial or
Introducing Limits of Confidentiality 7
interested (Edwards & Potter, 1992). Edwards and Potter suggest that speakers face a
dilemma of stake in interactions. Listeners treat what others say as being interested, thus
speakers construct what they say in such a way as to manage this impression or view by
producing talk that appears external or independent of the speaker’s interest. In doing so the
speaker rhetorically situates their talk to manage this impression or view.
The third DP premise is that discourse is both constructed and constructive (Edwards &
Potter, 2005). Discourse is constructed in the sense that DP considers how what is said is put
together in terms of words, categories, and idiomatic phrases within interactional sequences.
DP also treats discourse as being constructive in that discourse is examined for how people’s
reality and versions of the world, events, and actions are built and stabilised. Thus DP
studies construction as a discursive activity. In understanding construction, the DP
researcher comes to understand what is being constructed, what is the constructive work that
this discourse is performing, and what practices is this construction part of.
The data
An initial consultation between a provisionally registered psychologist who was in her
first year of professional training and a client was used as data in this study. The consultation
was originally recorded using a single digital video camera. The audio of the consultation
was copied from video and saved in stereo format as a WAV file. The consultation talk on
this file was then transcribed by the researchers using the transcription system developed by
Gail Jefferson (Jefferson, 1984; 2004) by repeatedly playing the audio in GoldWave, a
professional digital audio editor. The Jefferson transcription format captures pauses, stress,
and other speech delivery characteristics that enable talk to be analysed as a social activity.
Thus in addition to the verbatim text, the transcript displays instances of overlapping talk,
changes in intonation and emphasis, and timed pauses in the consultation conversation. A list
of common Jefferson notation symbols is displayed in the Appendix.
Introducing Limits of Confidentiality 8
Analysis focused on how the limits of confidentiality was worked up and managed by
both psychologist and client. To do this the Jefferson transcript was read a number of times
in conjunction with listening to the audio data. The data was examined for the action
orientation, situated, and constructive nature of the confidentiality talk as these reflect the
underlying theoretical premises of DP. In order to examine how the limits of confidentiality
was co-constructed by the participants, the following specific questions were asked of the
data: (a) What action is being done here? (b) How is this action accomplished and
constructed? (c) What is the situated nature of this talk? and (d) What rhetorical work does
this talk accomplish? These questions were asked of the data in a line-by-line fashion as the
conditional relevance of talk reflects the occasioned nature of discourse.
The key validation strategy in DP is readers’ evaluation of what is being claimed (Potter,
2003) as all research claims are accountable to the detail of the empirical material. All claims
and the data from which these claims have been drawn are presented so that readers can
check and judge what is being claimed. Further, the crucial role of participants’ own
orientations in establishing the adequacy of research claims were used to validate the
analytical claims (see Potter). That is, all research claims were grounded in the data, where
how the participants understood the interaction, was used as evidence of what occurred, and
what was understood by the participants themselves1.
1 In other qualitative approaches the robustness of analytic claims are often strengthened by inviting participants to make comment on analytic insights. In DP all research claims are grounded in the data. That is, the participants’ own understanding of the interaction form the analytic insights, thus there is an inherent robustness in the analytic claims and is the reason why DP does not provide participants with analytic claims for verification.
Introducing Limits of Confidentiality 9
Analysis and Discussion
Participants: Psychologist (P), Client (C) (00:38:00)2
1 P .t.hhh the other thing that we need to talk 2 about (.) .hhh uhm: is confidentiality. 3 (0.4) 4 C ok.= 5 P =ok:. confidentiality means that whatever 6 you say to me: is confidential that=is between 7 ↑us 8 C [ºmhmº] 9 P [.hh ] the same goes for the reports an 10 notes that I wr↑ite 11 C [ºmhmº] 12 P [.hh ] however, there are certain conditions 13 when confidentiality must be broken. 14 (0.5) 15 C ok= 16 P °=alri° .hhh one of these is for example if I 17 get subpoenaed tappear in c↑ourt (.) 18 C mhm 19 P uhm: my notes an I obviously (0.5) uhm 20 haveta (0.4) comply=with=the law. .hhh the 21 other is if at any point I think that you're (0.5) 22 uhm (0.7) in danger of harming yours↑elf or 23 harming somebody else. 24 (.) 25 I=am duty bound to report that. 26 (0.6) 27 however, you need to know that I’m not doing 28 it (0.4) with↑out telling you. 29 (0.4) 30 it’s not going=to=be (.) a sur prise to y↑ou 31 we=will discuss it before hand an I will tell 32 you .hh that I’m concerned and that I’m going to 33 report it on. 34 (0.4) 35 C ok.= 36 P =yr ok with th↑at 37 C =yes that's fine.
This section comes 38 seconds into the consultation and is the first time confidentiality is
mentioned. The psychologist introduces confidentiality through “the other thing that we need
to talk about (.) .hhh uhm: is confidentiality.” (lines 1 & 2). The first point of analytic
interest is the use of the word “need”. Need is a main verb (Greenbaum & Quirk, 1990) that
can be used to expresses obligation (Peters, 1995). “Need” works hearably in this instance
2 Transcription symbols are located in the appendix section. The format of the extracted data is consistent with DP presentation recommendations.
Introducing Limits of Confidentiality 10
with other thing to construct the upcoming confidentiality discussion as one in which the
topic and the timing of the discussion is not readily open to negotiation or question from the
client.
This restricting of client interaction is seen from the client’s response on line 4. The client
responds to the introduction of confidentiality with “ok.”. There is no question or elaboration
from the client about the upcoming discussion, only a single word response that is produced
with a downward, closing intonation. Leahy (2004) has found ok to function in therapy talk
as an indicator of a client’s compliance or agreement with what the therapist is saying or the
direction that the therapy talk is taking. The ok in this extract works in a similar manner in
that the psychologist understands the client’s ok as an indication that she agrees with the
direction that the discussion is about to take.
As an agreement token, Pomerantz (1984) has found that when ok comes straight after a
prior turn with minimal or no delay and an absence of hesitations then this is oriented to by
the next speaker as indicating agreement with the conversational trajectory. Agreement
tokens as the name suggested are utterances that are oriented to by the hearer as agreement
or compliance with how the interaction is unfolding (Schegloff, 2007). The client’s ok works
in this manner as seen from the psychologist’s response on lines 5 to 7.
The lexical choice of the word talk in line 1 rather than chat works to construct the
upcoming confidentiality discussion as something that will have an institutional
characteristic and be formal in substance. Antaki (2000) has demonstrated that by glossing
something in interaction as chat rather than talk projects the upcoming activity as something
that will be collaborative and informal. Thus by using the word talk, the discussion is
constructed as something that is formal and within the remit of the psychologist.
Staying with line 1, the psychologist uses the word we when introducing the need to
discuss confidentiality. This we could be heard as inferring a collective responsibility for the
Introducing Limits of Confidentiality 11
upcoming discussion and is commonly used to infer just that in therapy talk (Madill,
Widdicombe, & Barkham, 2001; Potter, 2005). But for this to be the case, grammatically we
must be used with verbs that are suggestive of shared knowledge (e.g., we understand)
(Greenbaum & Quirk, 1990). This we is referred to as the inclusive we. However when we is
used with verbs of communication, such as talk in this extract, we becomes the exclusive
“we” (Greenbaum & Quirk). This means that the upcoming confidentiality discussion is
being constructed as something that is the exclusive responsibility of the psychologist. It is a
discussion in which the client is not expected to play an active role. Most second graders
would have in their collective memory the utterance of teachers along the lines of “we
wouldn’t want to be doing that now children, would we”.
This introduction of confidentiality is consistent with the requirements set down by the
APS. Psychologists are required, within the formal parameters of the consultation, to discuss
confidentiality with the client regardless of whether the client wishes to do so or not. Thus at
this point the psychologist has constructed this introduction in a way that is consistent with
her ethical obligations. Further, she has done so in such a way that makes it difficult for the
client to refuse this introduction, though perhaps at some cost to future collaboration.
As mentioned previously, the psychologist orients to the client’s response on line 4 as an
agreement by continuing with the topic of confidentiality (line 5). This understanding is
displayed not only through the continuation of the topic but also in the psychologist’s
acknowledgement token =ok:.. Acknowledgement tokens are utterances such as ok and uh
hum that display an understanding that the previous speaker’s talk is not complete (Goodwin
& Heritage, 1990). The ok coming as it does in the third-turn position in a sequence of talk
(i.e., P line 1 is the first turn-at-talk, C line 4 is the second, and P at line 5 is the third), also
projects a shift to a new activity (Robinson & Stivers, 2001). The shift is outlining what the
upcoming confidentiality talk will contain.
Introducing Limits of Confidentiality 12
What is interesting is how the psychologist’s ok comes at a Transitional Relevant Place
(TRP)(Sacks, Schegloff, & Jefferson, 1974). TRPs are places in an interaction where one
speaker appears to have finished what they were saying and there is an opportunity for
another speaker to enter the interaction. The downward intonation at the end of “ok” on line
4 signals that this is the end of the client’s turn to talk and so projects a potential TRP (ibid).
This is how this utterance is understood as the psychologist moves to take up the
conversational space that the client is offering at this point.
The psychologist’s ok on line 5 is also latched on to the client’s line 4 ok. ‘Latched’
means that there is no interval or space between successive turns to talk (Jefferson, 1984).
Thus on line 4 the psychologist’s utterance is heard immediately after the client’s talk
without the normal 1-2 millisecond delay between speakers’ utterances. Such latched talk is
a way in which speakers can lay claim to the next turn-at-talk (Beach, 2001). The latched
talk, in this instance, makes it difficult for the client to do anything other than agree with the
conversation trajectory that is being set by the psychologist. Thus had the client had any
questions or concerns about the upcoming discussion, the latched talk by the psychologist
does not easily allow for such questions and concerns to be articulated. The psychologist,
therefore, takes the TRP and progresses the confidentiality conversation.
The next turn-at-talk by the psychologist is interesting in two ways. First, the psychologist
does not actually outline what confidential means only that what is said between
psychologist and client (lines 5-7) and written by the psychologist (lines 9-10) is
confidential. Second, the topic of breaching confidentiality is introduced and constructed as
something that is not open for negotiation or question from the client or the psychologist.
This is done through the use of “must be broken.” (line 13). Must as a modal auxiliary verb
(Greenbaum & Quirk, 1990; Peters, 1995) also expresses obligation. In this extract must
works to construct the limits of confidentiality as something that neither the psychologist nor
Introducing Limits of Confidentiality 13
client is able to question easily. This must is linked to certain conditions (line 12), thereby
inferring that such actions are not unconsidered but linked to specific actions or activities.
The above should not be taken to infer the client is a passive participant in this section of
the interaction. The client is participating in the interaction and we see this through the
client’s use of the continuer token mhm on lines 8 and 11. Mhm is an archetypal continuer in
conversation and works by the speaker passing up the opportunity to make a more
substantial turn to talk in the interaction (Gardner, 2001). Hutchby and Woofitt (1998) and
Jefferson (1984) argue that continuers indicate to the current speaker in the interaction that
the listener understands that a turn is in progress, that the speaker will hold the floor, and has
not completed his/her utterance. We know this because they come at TRPs in conversations
(Sacks, et al., 1974). Even though there is no falling intonation at the end of the previous
lines (7 & 10), they come at places in the interaction where one speaker appears to have
finished what they were saying. Thus they provide an opportunity for a conversational
partner to enter the interaction and take up a conversational turn.
On lines 8 and 11 the client does not take up this opportunity but instead utters a
continuer. Further, there is no pause between the psychologist’s previous turn and the
client’s continuer, suggesting that mhm is being used as a display by the client that she
understands that the psychologist has more to say on this topic. The absence of pause
between the previous speaker and the continuer is consistent with other research that has
considered the role of continuers in interactions (Filipi & Wales, 2003).
What is also interesting with these continuers is how they occur in overlap. This is seen at
lines 8 and 9, and 11 and 12. The continuer overlaps occur with audible in-breaths from the
psychologist. At these points the in-breaths are hearable as marking a beginning of a turn by
the psychologist (Wooffitt, 2003). That is, the psychologist orients to the continuers as just
Introducing Limits of Confidentiality 14
that: a signal to continue on with her conversational trajectory. Thus confidentiality is being
constructed as something that must be discussed and an issue that is psychologist lead.
It is interesting to note how the client responds when the psychologist introduces into the
conversation the notion that confidentiality can be breached. On line 15 the client produces
another acknowledgement token, ok=. This follows from a TRP and a 0.5 second pause.
What has come just before this is a change of topic by the psychologist from what
confidentiality is, to the conditions under which confidentiality no longer holds. Thus the
client displays an understanding that the topic of the previous talk is over and that the
psychologist has now moved onto a new topic.
This can be seen as having been understood as a signal to move forward by the
psychologist from her response of =alri on line 16. Alri as a shortened form of alright, serves
as a marker for the next activity to be attended to in this discussion on confidentiality (Filipi
& Wales, 2003; Roberts, 2000). The latching of the psychologist’s =alri to the client’s ok=
allows the psychologist to claim the next turn (Beach, 2001) and offers little opportunity for
the client to extend upon their acknowledgement. Thus the client is constrained from asking
any questions concerning the projected conversational trajectory by the psychologist’s move
to claim the floor through the latching of her response and following this with an audible in-
breath to hold the speaker’s role.
As the psychologist moves into accounting for the limits of confidentiality, the choice of
being subpoenaed as the first example is fascinating given the other examples that the
psychologist could have introduced. Following with the framing constructed by the
psychologist on lines 12 to 13, the use of this example provides a reason for breaching
confidentiality and at the same time formulates the constraint that this also places on the
psychologist (i.e., this is something that the psychologist has to do and has no choice in).
This is seen on lines 19 and 20, “I obviously (0.5) uhm haveta (0.4) comply=with=the law.”
Introducing Limits of Confidentiality 15
By constructing it in this manner, any blame for breaching confidentiality is unable to be
reasonably assigned to the psychologist because this is something that the psychologist
herself must do as a legal requirement.
Potter (1996) argues that this is a description-reason-constraint pattern ( description- lines
12-13; reason - lines 16-17; constraint -lines 19-20 ) and is typical of accounts when
someone is asked to do something and they find that they are not able to comply with the
request. Confidentiality is what is typically asked or expected of a psychologist but there are
instances when a psychologist is not able to comply with this and this non-compliance needs
to be accounted for. By constructing the breaching of confidentiality in this way, it portrays
the limits of confidentiality and justifies the subsequent actions that the psychologist will
take as something that the psychologist is obliged to take. This makes questioning
confidentiality and the psychologist’s actions difficult for the client, for to question the
action is to question law.
The second example that the psychologist uses to illustrate the limits of confidentiality is
seen on lines 21 to 23 and is the notion of self or other harm. Here we see an interesting
change from the first example. Being subpoenaed is an act that the psychologist cannot be
held responsible for. Kärkkäinen (2003) argues that “I think” displays a speaker’s epistemic
stance towards a proposition or perspective. But when a client discloses or acts in a way that
suggests that they may self-harm or harm others, the psychologist needs to make a number of
decisions concerning this information. One of these could be whether to breach
confidentiality. On line 21 the use of “I think” in this context constructs the decision to
breach confidentiality as something that the psychologist is solely responsible for. Indeed
this decision is a professional one as seen on line 25 where the psychologist refers back to
her institutional role through “I=am duty bound to report that.”. This second example also
Introducing Limits of Confidentiality 16
follows a description-reason-constraint pattern (Potter, 1996). This taking of responsibility
by the psychologist contrasts sharply with the legal example.
As can be seen from lines 12 through to 35 breaching confidentiality is presented as
something that is either outside the psychologist’s control or is bound up in the
psychologist’s ethical responsibilities. Either way, each construction makes it difficult for
the client to question the psychologist over this issue. Even though the psychologist’s turn-
at-talk has many TRPs, such as after law. spoken with falling intonation on line 20 and after
that. on line 25, the client does not join in the interaction.
The notion of being a danger to self or others is, by its content alone, an interactionally
delicate issue. This delicacy is displayed on lines 21 and 22 “ I think that you’re (0.5) uhm
(0.7)” as seen in the pauses of 0.5 and 0.7 seconds and uhm (Abell & Stokoe, 1999). Once
the notion of self or other harm is introduced the psychologist then outlines the action that
she must take. On line 27, a contrast is provided by the psychologist through the use of
however. According to Peters (1995) however works to emphasize a point of contrast in
explanations. In this instance it creates a contrast between what the psychologist is duty
bound to do, and how she will not engage in this course of action before informing the client
of her action (see lines 27 & 28). Thus even though she is required by the APS Code of
Ethics to breach confidentiality if a client were to divulge a serious intention to self or other
harm, the psychologist, before doing this, would inform the client that she were proceeding
with this course of action.
What is of note here is that the placement of this utterance makes it unclear whether the
same caveat of the psychologist informing the client that she is going to breach
confidentiality applies in the subpoenaed example. It is hearable as being related only to the
harm situation through the use of however and the “I will tell you .hh that I’m concerned and
Introducing Limits of Confidentiality 17
that I going to report it on.” (lines 31-32). This same relationship is absent from the
subpoenaed example.
The psychologist opened the discussion of confidentiality with an exclusive we (line 1).
On line 31 the second we is introduced “we=will discuss it before hand” where it refers to
breaching confidentiality over harm behaviour. By grammatically linking we with discuss
(Greenbaum & Quirk, 1990; Peters, 1995), the exclusive we is again invoked and any action
is retained as the domain of the psychologist.
Furthermore, on line 31 it is somewhat unclear just what is the it that will be discussed. It
could be inferred that the “we=will discuss it” encompasses the psychologist’s concern over
the self or other harm behaviour and the psychologist’s action of reporting the behaviour.
However on line 31 and through to line 33 this is not necessarily the case. The use of “I will
tell you .hh that I’m concerned and that I’m going to report it on.” hearably works to
constrain the limits of the discussion to the client’s behaviour and not the psychologist’s.
Thus although there will be some level of discussion should the client raise self or other
harm, it is unclear if this discussion will extend to the psychologist’s actions once this
information has been disclosed.
Lines 35 to 37 contain some interesting work in that the first ok= (line 35) from the client
is not heard as an affirmation of understanding with the prior speaker’s turn (Beach, 1999).
This is seen on line 36 where the psychologist asks explicitly if “Yr ok with that=”. This is
unlike the ok on lines 4 and 15 where the psychologist takes the client’s response as an
indication that they have understood the prior turns to talk. Thus the psychologist requires
from the client at the end of this confidentiality talk an explicit statement confirming her
acceptance of this course of action before moving onto the next topic. A similar explicit
acceptance pattern has been found in general practice settings when doctors make treatment
recommendations to patients (Stivers, 2006). Doctors explicitly elicit agreement from
Introducing Limits of Confidentiality 18
patients regarding the proposed treatment plan or course of action. By doing this, doctors
treat patients as having the right and responsibility to accept or deny treatment
recommendations. In a similar manner it can be seen that the psychologist is treating the
client as having the right and responsibility to deny or accept what the psychologist has
explained.
The client’s response on line on 37, through its situated nature, is an agreement linked to
the psychologist informing the client that there will be discussion regarding her concerns
about the client’s intention to self harm with the client before she takes any action. This
placement in the turn-by-turn nature of the interaction raises question about whether the
client has agreed to the other limit of confidentiality, the legal limitation.
Conclusion
Analysis has revealed that while the psychologist has adhered to the ethical obligation of
informing the client of the limits of confidentiality, how the client has understood this
informing remains open to interpretation and has not been unambiguously resolved. Further,
when the psychologist introduces confidentiality into the consultation she has done so in a
manner that has made it difficult for the client to question this introduction or seek
clarification about what is being discussed. This is potentially problematic in that should the
provisionally registered psychologist be subpoenaed and has not discussed this possibility
with the client beforehand, the client may feel that this is a basis for complaint against the
psychologist. What is often at the crux of complaints about psychologists to Registration
Boards is how clients have come to understand limits of confidentiality. Given that breaches
of confidentiality are Registration Board matters, this lack of clarity and the limiting of client
interaction in this consultation is concerning.
The analytical insights generated in this paper are consistent with findings reported by
Claiborn et al. (1994) and Hillerbran and Claiborn (1988). Both studies examined the factual
Introducing Limits of Confidentiality 19
knowledge of clients in relation to ethical issues including limits of confidentiality. In
relation to this, they found that clients tended to have an understanding of the general
concept of confidentiality however this tended to decrease when presented with specific
examples of confidentiality. That is, clients became confused concerning the circumstances
under which confidentiality could be breached.
The findings here are suggestive of how this confusion may arise in real-life
consultations. That is, the analysis raises questions about the opportunities that the client had
to seek clarification concerning the limits of confidentiality in this consultation which in turn
raises questions about the nature of informed consent. If clear and explicit opportunities to
ask questions and seek clarification are not made available for clients to take up in
consultations, then perhaps it is not surprising that confusion can occur. This was the only
time in this consultation when the limits of confidentiality was discussed.
This analysis illustrates how informing clients of limits of confidentiality can occur in real
life consultations. This is a response to the call by Claiborn et al., (1994) for examination of
what the client understands of ethical practices in therapy. It should be noted that this is only
one consultation with one provisionally registered psychologist and this study is illustrative
of the problem of adequately communicating in regards to the limits of confidentiality. DP
and conversation analysis (CA) researchers ordinarily work with a collection of data to
examine a phenomenon and its variant forms (Potter, 2003). However single case analysis
whereby a section of a single conversation is analysed is an accepted practice in CA
(Hutchby & Woofitt, 1998). Sacks (1992) argued in his lecture series that a fundamental aim
of conversation analysis is to describe singular events, as is the case in the analysis presented
here, as well as event-sequences. Single cases are often starting points for research and it is
with this in mind that this analysis is presented.
Introducing Limits of Confidentiality 20
The value of examining confidentiality within real-life consultation may provide an
additional aspect to the professional training of psychologists. In some medical schools (e.g.,
UCLA Medical School), examining the micro-conversational exchanges between doctors
and patients is a part of professional training programs. Given the client confusion
surrounding breaches of confidentiality that has been reported in previous research studies
(Claiborn et al., 1994; Hillerbran & Claiborn, 1988), it may be that clients do not have a full
and accurate understanding of these circumstances. By making explicit the micro-analytical
exchanges surrounding limits of confidentiality, we may be able to develop ways of working
that allow for a better informing of clients regarding ethical issues that may lead to better
client understandings. Examining these conversations is a step in the direction of
acknowledging how misunderstandings occur. Finally, this type of analysis invites
practitioners to become more aware of their own approaches to clients and the issue of
confidentiality. In this way practitioners are encouraged to reflect upon their own
communication practices and how the clients that they work with come to a shared
understanding of ethical practices.
Introducing Limits of Confidentiality 21
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Appendix 1
Common Jeferrsonian transcription notions (see Jefferson, 1984; 2004 for more detailed
information)
[ ] Square brackets reflect the start and end of overlapping speech.
Vertical arrows represent marked pitch movement, over and above normal
rhythms of speech.
Underlining Reflects vocal emphasis; the underlining within the word indicates how heavy
and where the emphasis is placed by the speaker.
quiet The degree signs capture hearably quieter speech.
(0.5) Numbers in these round brackets measure pauses in seconds.
(.) A pause that is too short to measure.
what me: Colons reflect the elongation of the prior sound. More colons reflect more
elongation.
.hhh In-breaths. The number of hs reflect the length of the in-breath.
however, The comma is a continuation marker indicating that the speaker has not
finished.
law. Full stops reflect a falling or stopping intonation (‘final contour’). This is not
reflected by grammar, it is reflected by intonation.
ok.==yr Equals signs indicate the latching of successive talk. This can be between
different speakers or within the same speakers talk. There is no interval
between what is said.
.t Indicates a tongue click.