To Tell or Not to Tell: The Question of Informed Consent
Author(s): Rhonda Williams, Ed.D., LPC, NCC
September 1, 2007
One of the most difficult ethical questions for professional school counselors to resolve is when to tell parents about a counseling session with their child and break confidentiality. This professional quandary is not easily resolved by looking at the ethical standards for ASCA or the American Counseling Association (ACA), nor is it defined clearly by reviewing the literature. It seems many of the experts have opposing views on this significant ethical issue.
ACA Section B. 3 states, “When counseling clients who are minors or individuals who are unable to give voluntary informed consent, parents or guardians may be included in the counseling process as appropriate.” Yet in the same paragraph the standard goes on to say, “Counselors act in the best interests of the clients and take measures to safeguard confidentiality.” Similarly, the ASCA Ethical Standards for School Counselors say, “Each person has the right to privacy and thereby the right to expect the counselor-client relationship to comply with all laws, policies and ethical standards pertaining to confidentiality.” However, the laws, policies and ethical standards often give the right of privacy right back to the parents, not the students.
ASCA A.2.f reminds professional school counselors that we must abide by laws as well as school board policy supporting confidentiality between a school counselor and the student. However, there are certainly some circumstances in which those confidentiality boundaries must be superseded such as when harm to self, harm to others or being harmed has been revealed in the counseling session.
There in lies the rub, because determining what constitutes harm to self, others or being harmed is often a gray area. Before such an incident arises school counselors should be prepared to answer what their decision-making point would be in breaking confidentiality. What is their value of confidentiality? Most professional school counselors would identify confidentiality as the bridge for connecting in the counseling relationship. However that bridge is not as sturdy when it comes to counseling minors and deciding when to break that bond.
When to tell parents about a counseling session has been identified as one of the most ethically confusing issues for a school counselor. Some argue that the parents have a legal right to know what their child is talking about in a counseling session. Other professional school counselors and counselor educators feel that a child has the right to the same standards of confidentiality as adults who enter into counseling. In a 1996, article by Herlihy and Corey, it was argued that it would be ill-advised for school counselors not to disclose information from a counseling session to a parent. Isaac and Stone, in a 2001 article, retort that breaking confidentiality can negatively affect a school counselor’s ability to build a supportive alliance with a student.
In 1995, Collins and Knowles asked students ages 13-18 about their perceived importance of confidentiality with their school counselor. The response from the students was overwhelming with 53 percent saying it was essential and 46 percent indicating it was important. Clearly, students view our commitment to confidentiality as a pinnacle on which they can build their relationship with the school counselor. It has also been said that the more we choose to disclose what is happening in a counseling session, the more degradation to our role as a student advocate.
Knowing how students value confidentiality between school counselor and student makes the decision to disclose the contents of a counseling session to a parent even more difficult. Consider this question: Would you break confidentiality if you found out one of your students was smoking cigarettes? Even though we are all aware that smoking can eventually lead to some pretty serious health risks and possibly death, would that be a case of harm to self? If the student were six years old would you disclose to parents? If the student were 12 would you be more or less likely to disclose to parents than if the student was 16?
However, clarifying the boundaries of confidentiality through informed consent both to students and parents allows for the bridge in the relationship between school counselor and students to be built on more solid and honest ground. To maintain an effective relationship with both parents and children it is ethically important to clarify what the boundaries of confidentiality are and how disclosure might occur if deemed necessary. Presenting informed consent at the beginning of a school year allows for school counselors to begin the year with clear guidelines about confidentiality.
Informed consent can be presented at many levels and in many ways. For parents, informed consent can be printed in the student handbook. This notification can delineate the role of the school counselor, while also explaining the process of counseling. Documenting the purpose and limitations of confidentiality in the student handbook provides important information to the students and parents in one format. However, putting information about the school counseling program and limitations to confidentiality in the handbook should not be the sole method of informed consent. School counseling brochures can also be used for that purpose. A brochure can explain the developmental, comprehensive, standards-based curriculum, while also giving details about the types of classroom guidance and small groups that are offered through the school counseling program as well as the reason for confidentiality and its boundaries. The ASCA code of ethics can be included in this brochure or at least referenced. Dissemination of this brochure can be an excellent method of notifying parents and students of the services provided from a school counselor, while at the same time covering issues of confidentiality.
Another method of distributing program information and informed consent might be through classroom guidance for students about the school counselor’s role along with the limitations of confidentiality. An in-service for the faculty, and a parents’ night presentation by the school counselor may be alternative strategies to disseminate the informed consent to all.
Although these suggestions may cover the initial effort of informed consent, it is important for school counselors to also consistently discuss informed consent with students who come to the counseling office. Initially explaining informed consent helps build a trusting, honest relationship with the student from the beginning. As the relationship develops, ongoing clarification is necessary to maintain a clear understanding of the legal and ethical limitations of confidentiality. By providing ongoing informed consent to the student, the school counselor is supporting the student in some decision-making power.
Unfortunately, however, there may be situations when the parent still demands the right to know what was said in a counseling session, despite various attempts at disseminating the meaning of confidentiality. This difficult decision is left to the school counselor’s discretion. There seems to be professional consensus of two factors in defining when to make this tough choice about breaking confidentiality. These two factors include the student’s age and maturity. Obviously the younger the students are, the less capable they are in making decisions and the fewer confidentiality rights they should have.
Assessing a student’s maturity may be more difficult. Welfel suggests checking the student’s understanding of the nature, risk and benefits of counseling and what consequences could occur if disclosure is mandated. These indicators may help school counselors decide how mature a particular minor actually is.
Working With Parents
Of course, evaluating each case on its own merits is the baseline in the decision-making process. Other ideas to use when a parent is insisting you break confidentiality include:
• Using empathic listening with the parents and allowing parents to vent
• Developing rapport and validating feelings
• Using professional judgment as to what constitutes the “appropriate” inclusion of parent and documenting the reasoning
• Asking student’s permission to share
• Reframing confidentiality as an important developmental step toward independent thinking
• Explaining that if the student does not trust the counselor’s commitment to confidentiality, the child may not share honestly
• Explaining the ethical codes to parents
• Clarifying that it is not the counselor’s job to be an informer between parents and child
• Suggesting parents themselves ask the child about the desired information
• Discussing different approaches parents might employ with their children
• Suggesting parents and child meet together with the school counselor
• Informing the students of their parents’ inquiry and suggesting ways to talk to parents
• Referring them to another counselor
• Consulting with a colleague
When considering breaking confidentiality, there are a number of other considerations and suggestions to take into account:
• Consider the child’s relationship with the parents.
• Consider child’s relationship with you.
• Prepare the student to take the lead in sharing information with parents.
• Ascertain child’s role his or her family.
• Consider cultural differences.
• Practice within the limits of your abilities.
• Ask the minor to provide permission to break confidentiality in writing.
• Keep accurate and objective records of all interactions.
• Recognize how your own values and beliefs may influence how dangerous you perceive students’ behaviors to be.
• Use the common sense doctrine.
• Maintain adequate professional liability coverage.
• Establish a network of peers to consult, both in and out of school.
• Engage in professional development regarding ethical issues.
• Request periodic in-services on policies regarding confidentiality.
• Educate stakeholders concerning the rationale of confidentiality.
• Ensure periodic updates of state laws and district policy.
• Establish in advance behaviors that might warrant breach of confidentiality.
There may be many times school counselors have to confront the request to break confidentiality by parent request or demand. As with many issues, a school counselor must be proactive by implementing a variety of methods of informed consent at the beginning of the school year, either in student handbooks or school counseling brochures. Research literature supports that confidentiality is the primary focus for students when coming to a school counselor. Confidentiality is also a clear defining function between our roles as school counselors and the roles of teachers and principals. Of course, when evaluating each case the school counselor’s primary concern will always be the best interest of the child when deciding to tell or not to tell.
Rhonda Williams Ed.D., LPC, NCC, is an assistant professor at the University of Colorado at Colorado Springs and the chair of ASCA’s Ethics Committee. She can be reached firstname.lastname@example.org.