introducing limits of confidentiality in real-life consultations: psychologist-driven or...

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

Formatted: Left


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.


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 demonstrateing 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


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


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 treatedoriented to 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 ins 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 examininglooking at 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.


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


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.


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.


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.


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

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the 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 previousior 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.





What is interesting is how the psychologist’s “ok” comes at a Transitional Relevant Place

(TRP 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

(ibidSacks et al.). 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



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 (lines 7 & 10), they come at places in the interaction where one speaker

appears to have finished whwhat they were saying. Thus they provide an opportunity for a

conversational partner to another speaker to potentially 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

(Wooffitt, 2003) by the psychologist (Wooffitt, 2003). That is, the psychologist orients to the


continuers as just 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 is

confidentiality is, to the conditions under which confidentiality no longer holds. Thus the

client displays an understanding that the topic of the previous talk about what is

confidentiality 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.”

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 ))-pattern 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

Formatted: Font: Not Italic


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 emphasizes 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 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


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 before hand, 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


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.


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

(e.g., 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.


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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.

introducing limits of confidentiality in real-life consultations: psychologist-driven or...

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