Counselling Dilemma: Couple Issues
You have been providing relationship counselling to a married couple for 4 months. The couple (Jeremy and Lucinda) have identified a number of issues, including a lack of trust, intimacy and communication. Jeremy had been involved in a brief affair, which he had confessed to his wife. It is largely this issue on which Jeremy and Lucinda have been focussing for the last 4 months.
You have been pleased with the development of the couple’s communication over this period. They have made some small, yet significant steps towards redeveloping trust and renewing their friendship.
Recently, Jeremy has requested a session with you alone to discuss a private concern. In this session, he discloses to you that he has been in contact with his previous lover. Since their affair, she has informed him that she has tested positive for Hepatitis C. Jeremy intends to have himself tested for the virus, but is reluctant to tell Lucinda about the virus and the meeting with his previous lover. He reasons that he may not have the virus, and doesn’t wish to worry Lucinda unnecessarily.
You are concerned about the possibility of Jeremy passing this virus onto his wife. When you raise your concerns with Jeremy, he states that he will be avoiding sexual contact with his wife until he finds out the results. You are also concerned about Jeremy’s commitment to developing trust with his wife and explore this with him. You would prefer that he discloses this information to Lucinda and so you inform him of your views.
Jeremy’s reaction is of dismay as he thought that his information would be treated confidentially in this private session. You think that Jeremy’s personal intentions are at conflict with his goals for his relationship.
How might you proceed with this dilemma?
This dilemma raises issues of client confidentiality. However it will only exist, if, after examining the situation, Jeremy refuses to tell Lucinda.
Assuming this is the case, the client/counsellor relationship has the added complication of the counsellor now being in possession of information that may have a direct bearing upon the physical well being of the clients.
The situation can be examined from two aspects:
With regard to the general counselling process ? considering the work already done and the momentum towards and focus upon a desirable outcome.
With regard to the counsellors ethical responsibility towards the ?unknowing? client.
If we look at the situation purely as a counsellor/client issue, that is one in which you as the counsellor believe that the progress made so far in the counselling program would be jeopardized if Jeremy did not disclose information to Lucinda, then we have some flexibility in our actions.
Jeremy has had a private session with you in which he disclosed certain facts believing the information would go no further. You indicate to him your concern that the withholding of this information could impede the progress he and Lucinda have been making in developing trust and re-establishing communication in the relationship. In an attempt to encourage Jeremy to tell Lucinda of his contact with his ex-lover, you take a positive stance and reiterate your support and commitment to the ongoing progress in this relationship. To this end, you inform Jeremy that you could assist him in tactfully handling this problem, with the aim of avoiding confrontation and a breakdown in communication.
In this case all you can do is point out your concerns, as part of your role as the counsellor. You ask Jeremy to consider the points you have drawn attention to, discuss the consequences of his actions or lack of, and inform him that the onus is on him as to whether or not he shares the information with Lucinda.
If you decide to break confidentiality and tell Lucinda of Jeremy?s contact with his ex-lover then you will be responsible for the consequences. Jeremy may lodge a complaint against you; he may sue you; he may refuse to continue counselling; Lucinda as well may refuse to continue; or both Jeremy and Lucinda may decide to continue the counselling process and the pressure would be on you to re-establish trust.
However, as stated this dilemma enters into the area of physical wellbeing and the responsibilities associated with the health and safety of your clients. That is both Jeremy and Lucinda. Jeremy has indicated that he may be infected with the Hepatitis C virus and is about to undergo testing to discover if this is the case. He doesn?t want to tell Lucinda as yet, since he may not have the virus and doesn?t want to worry her. He doesn?t want you to tell her either.
As a member of the ACA I am bound by the rules of conduct outlined by the ACA. This code of ethics emphasize the importance of maintaining client confidentiality to ensure a professional and safe environment for the counselling experience. However the code allows for exceptions.
?Exceptional circumstances may arise which give the counsellor good grounds for believing that serious harm may occur to the client or to other people.? (ACA, 2000, 7)
What you need to discern and then discuss with Jeremy is whether this case falls into the ?exception? clause. If you have data on Hepatitis C, or are already knowledgeable as to the severity of the disease then you can review the situation from an informed base. A question you could ask Jeremy is why he has given you this information, if it is to be kept secret. Jeremy may want some guidance and be confused as to what to do.
If you have no readily available information on the Hepatitis C virus you could tell Jeremy that you will get some more facts from the appropriate authorities and then you can further discuss this issue. Time is of the essence and so another appointment should be made as soon as possible. If you have the appropriate medical information then you can discuss the ramifications of withholding this information from Lucinda.
What you need to know is the incubation period for the virus and whether one test is all that is required to ascertain the presence of the virus. Presently the medical stance is that if you test negative for the virus you haven?t got it and life goes on as normal. Once these facts are known and you have discussed the matter further with Jeremy then it is decision time again. Jeremy may be fortified in his resolve not to tell Lucinda anything until he is tested, and the results are positive. He may want you to respect this decision. What you need to consider is whether this situation, based on the data you have, can cause potential harm to Lucinda. In other words is it safe to wait until the testing is done (bearing in mind that Jeremy will avoid sexual contact with Lucinda in the meantime) or do you feel that there is a threat to her physical well being?
This decision could be made easier if you have a consultation with a medical expert and a professional associate. If there is no danger then you have no ethical responsibility to disclose this information. As in the first situation (counsellor/client) you need to discuss with Jeremy the consequences of withholding the facts, and you have to look at the consequences to you if you breach this confidentiality based on the information on hand.
Confidentiality is always a concern of the client and the counsellor. The Code of Ethics outlines the rules and responsibilities of the counselling profession, but nothing is ever black or white. Questions concerning confidentiality can be addressed on the first client encounter. At this time the client can be told of the ethical responsibility to respect confidentiality and of the exceptions that apply. In this way the counselling program can begin from a base of honesty and mutual regard. From then on the counsellor is guided by the Code, by his/her expertise, by input from colleagues and professional associations and by instinct.
Wait till after the test. It is Jeremy’s responsibility to inform his wife, not yours. Strongly encourage him to tell her if he tests positive. This is a chance for him to be totally honest with her. If negative telling her will not help them reach their goal.
A number of issues present themselves here:
Does Lucinda know that Jeremy has had an individual session with the counsellor?
How will Jeremy manage to avoid sexual contact with Lucinda until he gets the test results?
How will this avoidance of sexual contact affect what is already a fairly fragile relationship at this stage?
How does Jeremy?s secrecy on this issue fit with his stated desire to improve trust and communication in the relationship?
Will keeping this serious issue a secret do further damage to their relationship?
Are the reasons for non-disclosure as stated by Jeremy (that he does not want to worry Lucinda unnecessarily) the real ones?
Are they valid reasons?
These are all issues that can be raised by the counsellor in discussion with Jeremy. Where the issue becomes a dilemma for the counsellor is in the potential for harm to be caused to Lucinda. This becomes even more relevant because Lucinda is also a client.
In my practice I tell clients early on in the introductory session exactly what my limitations on client confidentiality are, and apart from legal issues, these relate mainly to the areas of self-harm or harm to others. I explain that if I have reason to believe that the client may harm him/herself or someone else, I would discuss this with him/her and if I were still concerned about likely harm I would be looking to disclose this concern to other relevant parties. I would explain to the client exactly what I felt I should do and why.
I would have informed Jeremy again of these issues when he came to see me on his own, so he would then be able to make his decision on whether or not to disclose to me based on that knowledge, and would not in fact be ?dismayed?. A situation such as this underlines the need for the counsellor to make his/her confidentiality rules clear at the outset of the counselling process, and to re-state them if necessary.
In this case I would prefer Jeremy to make the disclosure to Lucinda himself ? possibly, if he wishes, in a session when they are both with me. I would certainly work with Jeremy to encourage him to talk to Lucinda about it and I would assist him in any way I could.
If he was determined not to tell Lucinda, I would not, at this point, be informing her myself. I would, however, continue to stress to Jeremy the need for self-evaluation of his reasons and also the need for immediate disclosure to Lucinda if the test results prove positive.
Previous responses cover well the need to manage these situations with a caring, sensitive and professional approach so that clients achieve the most positive outcome in an objective sense.
A couple of pointers I have found helpful:
I remind the client AS SOON AS THEY START disclosing information of risk of the warning they received in their initial session about the limits of confidentiality where there is serious risk to self or others. This allows the client to decide for themselves whether to continue speaking and ‘own’ the consequences.
Even when you are 99% sure that risk is very limited, it is always useful to discuss your duty of care with your client as even the knowledge that you have obligations to breach confidentiality if risk exists may be sufficient to motivate them to act promptly and responsibly.
The questions that I always ask to clarify whether to make child protection or firearm reports or act on other similar risk situations is :
==WHAT IS THE POTENTIAL OUTCOME IF I DO NOT ACT ? (to breach confidentiality, report child abuse, report access to firearms, advise a partner of serious potential risk)
==WILL I BE SATISFIED THAT I ACTED IN THE MOST APPROPRIATE MANNER IF LATER ON I HEAR THAT… (Lucinda developed HIV, the child received serious injuries or died, the firearms were used to harm others)?
Note that the first question says ‘potential’ not ‘likely’. We are not fortune tellers and cannot predict what WILL happen. We may underestimate the potential for harm, not least as client self report can be unreliable and we cannot know all the information to make an objective assessment.
It is also impossible – in situations where a potential risk has been identified – for the counsellor to make the decision whether the client(s) would be better served by maintaining the existing counselling relationship or risk client rejection of what may be their only support source.
Very often, the duty of care towards clients and others to protect them from risks will outweigh both the client’s need for that specific counselling relationship (there are other counselling sources) or the need to maintain a fragile relationship.
How will Lucinda – also your client – feel about your failure to act if she develops HIV and learns you could have protected her?
In relationships, honesty and integrity about significant issues is essential. It is unlikely the relationship would remain sound if Jeremy places his own need to maintain the relationship higher than his partner’s health and safety.
But what about if Jeremy says he plans to suicide if Lucinda learns the truth? There will be many occasions when the issues are extremely cloudy, and asking these questions helps to clarify things a little.
It is invaluable and probably essential to also discuss the issue with professional organisations and colleagues.
Thank you for that very informative and thought-provoking article on client confidentiality and the dilemma of dual-responsibility. At a recent peer support meeting this very issue was the topic of debate and you have provided further insight, many thanks.
Dear Zahava, Wendy & Chris,
All the approaches that you give are relevant… I am nmore drawn to Zahava’s argumentations.
I am a currently doing a PGD – in Counselling in Nairobi, Kenya and I appreciate reading articles on the AIPC website. Thanks for all the good work
Yours sincerely,
Dennis.
Thanks for the positive feedback Dennis!
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Hi,
I am presently working with a couple and found the suggestions presented insightful. Thanks a lot for the articles you present as they give a wider perspectives and help to give a comparison with the clients?I work with. Thanks a lot for the insights.
Merab.
I believe that counsellor’s goal is to help others to understand themselves. I think all information must be shared with the wife during the counselling session. Counsellor should assist Jeremy to overcome his fears to be rejected and unwanted, and assist the wife in learning to forgive Jeremy at any circumstances. Irina, student.
As with individual when working with couples it is necessary to lay the ground rules(openness, honesty, willingness to participate) in the first session. If we are clear with clients that the rules are part of the consultations then we can refer back to them in times such as the case study.
The counsellor needs to create a safe and open environment for the individauls as well as the couple and get commitment from the individuals at the beginning that both want to mend the relationship .
Jeremy seeking an individual session would be an indicator to me that there is something not right and I would be discussing this in the session (again seeking commitment and clarification) with both as a way of bringing out the issue.
Then hopefully the counsellor would not find them self in a situation like this.
Overall I believe it is about clarity, commitment and preparation on the counsellors part.
I am a student at AIPC and this was helpful information. I have to say that I was in a dilemma in reading this story and you have set it right for me. But of course there has to be ground rules and what would be the point in being honest and open and mending your relationship if you are going to a sneak session with your couselor. I will remember that. Thanks.
Something not considered is that Hep C is very rarely passed on through
sexual fluids. It is passed through blood to blood contact.
Pippat
Thank you for that comment. So many people are misinformed about the Hep C virus. If more people were to educate themselves then perhaps there ignorance would go unnoticed. Glad to see that you did your research and know your stuff. Now we just need the rest of the ignorance to become education that would take the stigma away from people who have the virus. They are people too who deserve to be respected not criticized for other people’s ignorance.
Jeremy will be wondering if the development is a deal breaker between him and his wife, at this sensitive time. He may need some time to process the implications and reflect within his moral framework. Adding pressure to him might be counterproductive. Giving him the onus is good. if he has demonstrated responsible behaviour previously, could you trust him to do as he says for a little while? After the result comes in, it could be tricky, if he went into denial. So best thing is to find out, what happens if the result comes in positive Jeremy? What do you intend in that circumstance? If he seems unsure, might not be wise to trust him to protect his wife. If he says something like ‘oh well I would just have to face up to it and the consequences whatever they are’ you could then offer to help him pick his way through it if that happened. be guided by his responses. And by your own senses telling you how responsible and reliable he is, based on evidence. Some would argue that his affair might point to some evidence that he tends to avoid facing up to areas of conflict, and that might be enough in itself, if nothing else sways you, to go with protection of his wife first and foremost.