Adolescents' Attitudes Towards Confidentiality Between the School Counsellor and the Adolescerit Client. NERIDA COLLINS AND ANN D. KNOWLES.
Adolescents’ Attitudes Towards Confidentiality Between the School Counsellor and the Adolescerit Client NERIDA COLLINS AND ANN D. KNOWLES Swinbume University of Technology
bilities as being directed to the parents, next of kin, or guardians (p. 5). t is increasingly acknowledged that confidentiality is relative
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rather than absolute in any counselling relationship. This is particularly the case for minors receiving counselling at school, where third parties such as parents and teachers frequently have access to information about an adolescent client. The Australian Psychological Society’s Code of Professional Conduct (1986) states that minors are unable to provide voluntary, informed consent in consulting relationships, although current research does not necessarily support this view. The current study investigatedadolescents’ attitudes to confidentiality in situations that may commonly arise in school counselling. The study also investigated the third parties to whom adolescents believed information should be disclosed by a counsellor. Respondents were 303 male and 254 female students attending three single-sex nongovemment schools. Ages ranged from 13 to 18 years. Results suggested that the adolescents’ attitudes to confidentiality generally corresponded with adult views. Many adolescents wanted more autonomy regarding disclosure of information obtained in a counselling situation than the APS code provides. Parents were the only third party to whom the adolescents generally believed disclosure should be made. There were few age differences, but a wide range of opinions were evident, with female adolescents consistently more strongly in favour of confidentiality than males.
It has long been argued that effective counselling is compromised without the assurance of confidentiality, but it is also increasingly acknowledged that confidentiality is discretionary (Beeman & Scott, 1991; Bongar, 1988; McMahon, 1992). This is especially so for adolescents in a school counselling situation, where third parties such as parents and teachers may have access to information about the adolescent client Also, the introduction of mandatory reporting of child abuse in most Australian States requires that such information must be reported to welfare authorities (Hall, 1993). The Australian Psychological Society’s Code of Professional Conduct (the APS code; 1986) provides some guidance in relation to minors and confidentiality. Section B3 states: When working with minors (that is, individuals under the age of 18 years) or other persons who are unable to give voluntary, informed consent, psychologists must protect these persons’ best interests and will regard their responsi-
This appears to imply that all minors are unable to give voluntary, informed consent as there is no distinction made between younger children and adolescents. Also,it is uncertain whether the “best interests” clause implies that the rights of the minor are subject to the rights of the adult (Gustafson & McNamara, 1987). Thus the APS code does not encourage psychologists to recognise autonomy in their adolescent clients. In areas other than psychological consultations there has been an increasing tendency to extend to capable minors the legal rights accepted by adults (Kaser-Boyd, Adelman, & Taylor, 1985; Melton, 1981). In some American and Australian states, minors may seek confidential advice and treatment in situations where obtaining parental consent could jeopardise the likelihood of their seeking help, such as substance abuse, pregnancy, or sexual abuse (Melton, 1981). New South Wales and South Australia have both passed legislation giving minors 14 years and over the right to consent to medical treatment. However, in both Australia and the United States, minors’ legal rights have centred on the right to medical treatment, not psychological services. In England, a major decision regarding minors’ rights to give consent was the case Gillick v. West Norfolk and Wisbech Area Health Aurhon’ty (1986; see Hamson, 1987). Mrs Gillick, the mother of five daughters under the age of 16 years, sought a declaratory judgement that the local health authority’s provision of family planning services for everyone, regardless of age, was unlawful. The House of Lords declined to issue a judgement in her favour in 1986. The case is consistent with the view that, under certain conditions, the consent of a minor may be valid (Harrison, 1987). The notion that adolescents may possess the maturity to make informed and competent decisions can be related to cognitive development theory Cpraget, 1953). According to Piaget, adolescents aged 15 and over have typically developed the capacity for abstract, scientific thought. In an extension of Piaget’s theory, Elkind and Bowen (1979) proposed that adolescents develop a belief in an imaginary audience (believing that others in their immediate vicinity are as concerned with the adolescent’s behaviour as they are themselves) in conjunction with their newly acquired abstract reasoning powers. This belief. in an imaginary
Address for correspondence: Ann Knowles, Department of Psychology, Swinbume Unlverslty of Technology, John Street, Hawthorn VIC 3122, Australia.
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audience declines as formal operational abilities become better established. This suggests that adolescents aged 15 years and over may make adult-like decisions, while younger adolescents may be more self-conscious and perhaps more concerned with confidentiality. Research has also indicated that minors, particularly those over 15 years, may be able to make informed and competent decisions regarding psychological treatment, although minors aged 11-14 may be more transitional in such reasoning (Grisso & Vierling, 1978; her-Boyd et al., 198 1). Thus there is not a great deal of support for the assumption, inherent in the APS code, that minors 15 years and over cannot provide valid consent. If adolescents are capable of giving informed consent, then their views about when or to whom counselling psychologists should breach confidentiality is of interest, but there has been little research in this area. Research into community attitudes towards confidentiality in the psychologist-client relationship has been largely confined to adults. An Australian study found that respondents supported limited, discretionary confidentiality, and were generally not in favour of disclosure to third parties (Knowles & McMahon, 1995). The current study investigated adolescents’ attitudes to disclosure of information that may commonly be divulged to a school counsellor, such as information about sexual behaviour, physical and/or sexual abuse, substance abuse, crimes against property, and dangerousness to self or others. The study also investigated adolescents’ beliefs about disclosure of such information to third parties, and explored whether adolescents aged 15 and over differed from younger adolescents in their attitudes to confidentiality. The study used a confidentiality questionnaire based on that used by Rubanowitz (1987).
Method Participants Four Melbourne single-sex and two coeducational nongovernment schools, which employed counselling psychologists as school counsellors, were asked to participate in the study. Three single-sex schools agreed to participate. Respondents comprised 303 male and 254 female students attending these schools (one boys’, two girls’ schools). Age of respondents ranged from 13 to 18 years. Eighty per cent of respondents lived with both parents, 1 1 % with their mother, and the remainder with a parent-stepparent family relationship, or their father. Measures Demographic information including gender, age, school attended, and year level was obtained. The confidentiality questionnaire comprised items which gave respondents a choice of responses and Likert-style items. Of the fixedchoice items, one examined respondents’ endorsement of absolute confidentiality, four asked whether a school counsellor should breach confidentiality if a teenage client revealed they were frequently drunk, being physically and/or sexually abused, using contraceptives, or pregnant. Five items explored which, if any, third parties (parents, teachers, or police) should be informed if a teenage client admitted to shoplifting, arson, heroin/cocaine use, threats of serious harm against another (for this item the potential victim was included as a third party), or intention to commit suicide. Four Likert-type items required responses on a 5point scale with responses ranging from strongly agreelalways (1) to strongly disagreehever ( 5 ) . Two of these items probed respondents’ beliefs as to whether confidentiality generally should be breached to concerned adults, NOVEMBER 1995 rY AUSTRALIAN PSYCHOLOGIST
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and two explored whether confidentiality should be breached to specific third parties in situations where the teenage client was being physically and/or sexually abused (welfare authoritiedpolice) or was HIV+ (client’s partner). Items relating to suicide, contraceptive use, pregnancy, and AIDS were restricted to adolescents aged 14 years and over since these issues were considered by the participating schools to be’potentially disturbing for younger adolescents. All items referred to the “school counsellor” rather than “psychologist”.
Procedure Questionnaires were completed in school. The purpose of the study was explained and confidentiality assured. Informed consent was obtained from respondents and they were advised that participation was voluntary and anonymous, and that they were free to withdraw from the study at any time. The terms client and confidentiality were explained. The client was described as a student seeing a school counsellor for help with personal problems, and confidentiality was described as “keeping secrets”. Students were asked to imagine themselves as the client in each of the situations described. Responses to the Liken scales were scored so that a high score indicated strong endorsement of confidentiality (i.e., that the counsellor should not breach confidentiality) and a low score indicated belief that information should be disclosed (i.e., that a school counsellor should breach confidentiality). Based on research indicating that minors aged 11-14 may be more transitional in reasoning about confidentiality and consent issues, respondents were grouped into two age groups: 12-14 years (29%) and 15-18 years (71%).
Results Preliminary analyses revealed very few significant differences in responses from the two girl’s schools sampled, and their responses were grouped together for all subsequent analyses. In the following analyses, only significant age and gender differences are reported, and because of the large number of chi square calculations the significance level accepted was p < .01. It should be noted that frequently percentages do not add to 100%because respondents could give multiple responses.
Absolute Confidentiality When asked how important absolute confidentiality between a teenage client and a school counsellor is for successful counselling, 53% of students said confidentiality was essential, 46% said it was important and 2% said it was not really important. Two Likert items related to breaches of confidentiality to concerned adults; these items were scored from 1 to 5 with a high score indicating that confidentiality should not be breached. Overall mean responses to the items “A concerned adult (e.g.. a parent or classroom teacher) should be given information from a school counsellor without a teenage client’s permission” (N = 550, M = 3.82) and “A counsellor should be able to discuss a teenage client with other health care professionals (such as the family doctor, school nurse or other counsellors), without the client’s permission” (N = 550. 3.16) indicate moderately high levels of support for confidentiality, and a general unwillingness to disclose to concerned adults. Two 2 x 2 ANOVAs examined whether mean responses to these items differed according to gender and/or age group(l4 years or younger, 15 years and over): For both items, females (n = 252, M = 3.92 and 3.39 respectively) scored significantly higher than males (n = 298, M = 3.73 and 2.96 respec-
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ADOLESCENTS’ ATIITUDES TOWARDS CONFIDENTIALITY
TABLE 1 Percentage of Male and Female Respondents Aged 14-18 Years Agreeing, Disagreeing, or Unsure as to Whether the School Counsellor Should Tell Parents in Situations of Contraceptive Use, Pregnancy, and/or PhysicaVSexual Abuse
TABLE 2 Percentage of Adolescents Agreeing that Confidential Information Should be Disclosed by Situation and Third Party, and Percentage Saying that Information Should be Disclosed to No-one.
SITUATION
SITUATION
Agree CONTRACEPTION % 33 Males 13 Females PREGNANCY Males 41 Females 15 PHYSICAUSWUAL ABUSE 61 Males Females 47
RESPONSE Disagree Unsure 52 79
% 16 8
221 174
43 74
17 11
221 174
9 16
30
221 174
%
THIRDPARTIES Parent Teacher Police
n Shoplifting Arson HerddCocaine Serious harm to another suicide
NO-ONE n
%
%
%
%
45 44
7 12 10 22 14
11 20 16 27 13
51 46 39 18 19
54 48 75
557 557 557 557 395
Note: Percenlagea do not add lo 100 because multip+a rssponms were posrlbb.
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tively), F(1) = 8.03, p c .005 and F(1) = 21.46, p c .001. There were no significant age differences. Sexuaiity, Contraception and Pregnancy Students aged 14 years and over were asked whether or not parents should be told if a teenage client tells a school counsellor she is using contraception (the pill) or is pregnant. Responses are given in Table 1. Results show no strong agreement among respondents that the school counsellor should breach confidentiality regarding contraceptive use and pregnancy. Chi square analyses showed the gender differences in these responses were significant for both the contraceptive item, x2(2) p = 32.01, p c .001, and the pregnancy item, x2(2) = 41.78, p c .001). Females were considerably more in favour of confidentiality in these situations than were males. Physical and Sexual Abuse Responses in Table 1 show a high level of uncertainty as to whether the school counsellor should breach confidentiality and inform parents if physical and/or sexual abuse by a family members is disclosed, and the gender difference was significant, x2(2) p = 12.41, p c .002. Responses to the Likert item: “Welfare authorities and/or police should be told by the school counsellor if a teenage client admits to being physically and/or sexually abused by a family member” were analysed by a 2(gender) x 2(age group) ANOVA. The overall mean response (M = 2.33, N = 543) indicated only weak support for welfare aufhorities being informed of physical and/or sexual abuse of a minor. Females (n = 246, M = 2.49) scored significantly higher than males (n = 292, M = 2.21), F(1) = 7.53, p c .006, and there were no age differences. Table 2 was drawn up to indicate the third parties adolescents believed information should be disclosed to in various situations, and the proportion of respondents who did not believe any information should be disclosed in these situations. Substance Abuse Regarding alcohol abuse, 48% of respondents (40% of males and 57% of females) chose the response: no-one should be told if frequent drunkenness was disclosed. This gender difference was significant, x2(1) = 15.27, p c .001. Table 2 gives the percentage of students who agree that confidentiality should be breached regarding the use of illegal drugs such as cocaine or heroin, and the third parties to whom these breaches should occur. Parents were the third party to whom disclosure was most approved, with only low
levels of support for disclosure to teachers or police. Over a third of the sample (39%) thought confidentiality should not be breached on this issue. Crimes against Property Table 2 shows that approximately half the students did not think confidentiality should be breached in the situation of an admission of shoplifting or arson. The gender differences for shoplifting (44% of males and 53% of females said noone should be told) and for arson (47% of males and 53% of females said no-one should be told) were significant, ~ ~ ( 2 ) = 13.90, p c .001 and x2(2) = 1 2 . 2 0 , ~c .001 respectively. Dangerousness to self or Others Table 2 indicates the percentage of respondents agreeing that third parties should be informed if a teenage client threatens to seriously harm another person. For this item, the intended victim was included as a third party, and 42% of students agreed that this should happen (this response choice is not included in Table 2 as it was only available for this item). Only 18% of respondents (13% of males and 23% of females) said the school counsellor should not tell anyone about a threat of danger, and this gender difference was significant, x2( 1) = 9.3 1, p < .002. Table 2 also gives results for the item regarding disclosure of an intention to commit suicide (this item was only asked of students 14 years and older). A high percentage said parents should be told, and only 19% said no-one should be told (14% of males and 27% of females), x2( 1) = 10.99, p c .001. A 2(gender) x 2(age groups 14-15 and 16-18 years) ANOVA investigated gender and age group differences in responses to the scaled question “The counsellor should tell the client’s partner if the client is HIV positive (AIDS)even if it means going against a client’s wishes”. Females (n = 164, M = 2.71) scored significantly higher than males (n = 203, M = 2.11), F(1) = 17.51, p < .001, although overall these mean responses indicate that students were very undecided about breaching confidentiality in this situation.
Discussion The schools agreeing to participate in this study were all single-sex schools. The students sampled from these schools strongly endorsed confidentiality within a school counselling situation, with 98% agreeing that absolute confidentiality was either essential or important. There was only qualified support for the position that concerned adults such as parents, teachers, or health care professionals should have access to counsellor-client information, and little apparent recognition that the duty of care school authorities owe their students may include divulging information to NOVEMBER 1995 Yr AUSTRALIAN PSYCHOLOGIST
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parents and guardians. This strong trend to secretiveness could be interpreted as supporting Elkind and Bowens’ (1979) argument regarding the self-consciousnessof adolescents. Nevertheless, the most noteworthy finding regarding age trends in the current study was the almost complete lack of age differences between students from 12 to 18 years in their beliefs about disclosure. Students were asked about disclosure of information to parents in situations where a student told a school counsellor that they were using contraceptives, were pregnant, or were being physically or sexually abused. Female students were very strongly against disclosure of contraceptive use or pregnancy, and less than half of the male students agreed to such breaches of confidentiality. For physicallsexual abuse there were higher levels of agreement that confidentiality should be breached, but still only approximately 50% of students agreed that disclosure to welfare authorities or the police should happen. This is of particular relevance given that a mandatory obligation for teachers and psychologists to report such abuse is currently being introduced in the state of Victoria Results in Table 2 show that students gave very different responses regarding the appropriatenessof breaching confidentiality according to situation. There was no unanimity of views regarding disclosure of shoplifting and arson, and over a third of the sample did not believe heroin or cocaine use should be disclosed. However, there was much greater agreement that confidentiality should be breached in cases of clear danger to self or others, with less than 20% of the sample saying such situations should not be disclosed. Considering third parties to whom information could be disclosed, if studentsendorsed release of information,it was to parents. Only a small minority of students were in favour of release of information to teachers or police. It is very striking that the situations clearly involving danger were the situations where these adolescents were most in favour of breaching confidentiality, and this is consistent with the general principles in the A P S code. The other striking result is that there was little recognition by the students that teachers and other concerned adults may have a right to information, either because the students are minors or because the adults may have a legal obligation to disclose certain information. Psychologists, particularly those working in schools, may need to develop adolescents’ awareness of legitimate limits to confidentiality to ensure that their clients are able to give informed consent to counselling. Overall, these adolescents’ beliefs corresponded closely to those of adults (Knowles & McMahon, 1995) and suggest a fairly sophisticated understanding of confidentiality issues. For example, the respondents made a clear distinction between sexual behaviour, with a considerable majority of both male and femide students opposed to the disclosure of contraceptive use and pregnancy, and danger to self or others, where there was strong endorsement for disclosure of potential harm to others or to the self. There was also most willingness to disclose to a range of third parties on this issue. Such distinctions correspond to the provisions of the APS code. There were marked gender differences, with females always less in favour of disclosure than males. While the differences on contraception and pregnancy may be explained by the traditional perception that these matters are
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of greater personal relevance to females, the general trend is difficult to interpret as it does not appear in research with adults (Knowles & McMahon, 1995). and this finding should be treated with caution until further research in coeducational settings is available. However, regardless of gender, a notable finding was that there was a considerable division of opinion about disclosure amongst the students sampled, with responses approaching unanimity only on the dangerousnessitems. In conclusion, this study has produced evidence that adolescents strongly desire respect for their autonomy as clients in a school counselling relationship. Adolescents may also want more autonomy in other psychologist-client relationships than is provided for by the APS code. The authors suggest that, on the basis of these and other empirical results, the provisions of the A P S code regarding confidentiality, informed consent, and minors should be re-evaluated. Cumntly the APS code does not differentiate between clients aged 7 and clients aged 17 years; this is in accord neither with the practice of many other professions and organisations dealing with adolescents, nor with the findings of empirical research.
References Australian Psychological Society. (1986). Code of professional conduct. Melbourne: Author. Beeman, D.G., & Scott, N. A. (1991). Therapists’ attitudes toward psychotherapy informed consent with adolescents. Professwnal Psychology: Research and Practice, 22,230-234. Bongar, B. (1988). Clinicians, microcomputers, and confidentiality: A survey of psychologists in seven states. Professional Psychology: Research and Practice, 19.286-289. Elkind, D, & Bowen. R. (1979). Imaginary audience behavior in children and adults. Developmental Psychology, IS,33-44. Grisso, T., & Vierling. L. (1978). Minors’ consent to treatment: A development$ perspective. Professional Psychology: Research and Practice. 9,412-427. GUck v. West Norfolk and Wisbech Area Health Authority, AC 112 (House of Lords, 1986). Gustafson. K.E.. & McNamara, J.R. (1987). Confidentiality with minor clients: Issues and guidelines for therapists. Professional Psychology: Research and Practice, 18,503-508. Hall, A. (1993). Introduction to mandatory reporting. (Health & Community Services Victoria Memorandum). Harrison, M. (1987). Adolescent issues and the law. Family Matters, 19, 18-20. Kasa-Boyd, N.. Adelman. H.. & Taylor, L. (1985). Minors’ ability to identify risks and benefits of therapy. Professional Psychology: Research and Practice, 16,411417. Knowles. A., & McMahon. M. (1995). Expectations and preferences regarding confidentiality in the psychologist-client relationship. Australian Psychologist, 30,175-178. McMahon. M. (1992). Dangerousness, confidentiality,and the duty to protect. Ausnalian Psychologist, 27. 12-16. Melton, G.B. (1981). Children’s participation in treatment planning: Psychological and legal issues. Professional Psychology: Research and Practice, 12,246-252. Piaget, J. (1953). The origin of intelligence in the child. London: Routledge & Kegan Paul. Rubanowitz. D.E. (1987). Public attitudes toward psychotherapist4ent confidentiality.Professwnal Psychology: Research and Practice. 18,613-618.
