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Prevention of Social Workers, Counselors, MFT's Medical Errors #1
2 CEUs Prevention of Medical Errors for Social Workers, Counselors, & MFT's

Section 4
Patient Safety: 3 Confidentiality Boundaries
for Self-Harming Clients

Question 4 | CE Test | Table of Contents | Medical Errors CEU Courses
Counselor CEUs, Social Worker CEUs, Psychologist CEs, MFT CEUs

3 Boundaries to Confidentiality
Boundary #1 - Intent
The first ethical confidentiality boundary is intent.  In the case of a self-harming client, one of the first criteria to determine if the disclosure of information is appropriate.  In many cases of self-harming clients, their actions could be misconstrued as a suicide attempt when in fact there are many other reasons for the self-mutilation.  For instance, many self-mutilating clients use their injuries as a coping strategy for stress or other issues. 

Emotional distress, especially, becomes a strong incentive to "release feelings" but without the intention to commit suicide.  In fact, one of the criteria for self-mutilation is to injure oneself without the intent of death.  So one of the points I consider is whether or not the client is in fact a self-harmer or if he or she attempted suicide. 
Wendy, age 21, had been referred by one of her professors to Ellen, on the university counseling staff, after her professor noticed slash marks on her wrists.  When Ellen asked Wendy about it, she stated, "I wasn’t trying to kill myself.   It just helps relieve the pressure when I have finals."  Ellen asked Wendy if she would submit to a physical examination, which she did. 

However, upon taking the exam, the physician discovered that the cuts in Wendy’s arms were of such a depth and angle to cause serious damage upon infliction.  Because of this new information, Ellen had reason to believe that Wendy had in fact tried, but failed, to kill herself. 

Because of this new information, Ellen asked Wendy if it would be appropriate to contact her family and notify them of her attempted suicide.  Wendy rejected the idea of contacting her parents.  She also stated that she felt that she may try again.  Ellen proceeded to inform her of the need to be placed on an inpatient unit to prevent her from further self-harm.  Think of your Wendy.  If you feel she has a danger of suicide, have you informed her ahead of time regarding your legal responsibility to prevent her from committing suicide?
Boundary #2 - Parental Disclosure
The second confidentiality boundary is parental disclosure.  In the cases of self-mutilation, that is not an attempted suicide the confidential boundaries become more and more blurred.  Because most minors are not allowed self-determination, privacy rights extend to their parents or legal guardians. 
Therefore, it is both legally and ethically appropriate to inform a parent of their son or daughter’s self-mutilation.  Although the client may protest and expressly forbid his or her counselor to not disclose this information, it is in their best interests to break the confidentiality boundaries in these instances.  Obviously an initial session with the client needed to inform him or her of your obligation regarding self-harm.
Kara wore long-sleeve shirts and pants to cover her cuts from her self –mutilation.  Her school counselor told Kara that their conversation would be kept confidential unless she was at risk of harming herself or others. After initial introductions, the counselor stated that she was concerned that Kara was engaging in self-harming behavior.

Kara quickly replied that she was not suicidal. She disclosed that she has been cutting delicate marks into her arm and legs with a razor blade. Kara told the counselor that the self-injury helps her to relieve the tension and stress accompanied with her full schedule of Advanced Placement classes. The counselor, who was unfamiliar with self-harming behaviors, immediately considered the self-cutting to be a suicidal action.

At the end of the counseling appointment, the counselor told Kara that she felt she was at risk of seriously harming herself and that she had to report this behavior to her parents. After contacting Kara's parents, the counselor documented the nature of the counseling session and referred her to a licensed psychiatrist.  Even though the counselor may have misinterpreted Kara’s intents and actions, she made the ethical decision to disclose the self-harming behavior to Kara's parents based on the information she had regarding self-mutilation.  Think of your Kara.  Do you believe it is your ethical duty to report minor clients’ self-harming behavior to his or her parents?
Boundary #3 - Hospitalization
In addition to intention and parental disclosure, the third confidential boundary is hospitalization.  In the case of self-harming clients, there is always the potential for serious injury or even death should the client make a mistake and unintentionally harm him or herself.  Hospitalization is a crossing of the confidential boundaries as it brings in a third party, but generally it is in the pursuit of the clients own protection. 

However, new questions have been raised in the last few years about the effectiveness of hospitalization regarding self-mutilating clients.  Specifically, does this kind of treatment only make the client more dependent on others and not him or herself to keep from self-harming?  Or does it in fact accomplish what many practitioners believe it accomplishes, mainly, isolates the client until he or she no longer has the urge to self-harm? 
Jeanette, age 20, was a severe self-harmer.  She used several methods, including cutting, burning, biting, and using a piece of string to cut off circulation to certain parts of the body.  Believing her to be a danger to herself, her therapist, Joan, ordered her to be hospitalized for several months.  After this time, Jeanette left the hospital, but still with the urge to self-harm and because she felt betrayed by her therapist Joan, she became more extreme in her methods. 

Eventually, her hand slipped while cutting, and she began to lose a great deal of blood.  She finally decided to call an ambulance and she was taken to the hospital and readmitted.  When asked if she were willing, to return to her therapist, Jeanette stated, "No way!  She was the one who put me in that awful place and it only made things worse.  How do I know she won’t do that to me again?" 
Evidently, hospitalization did not help Jeanette’s urge to self-harm.  So the violation of the confidentiality boundary only increased her condition and destroyed her trust in her therapist.  Think of your Jeanette.  Could his or her trust in you be jeopardized if he or she were recommended for hospitalization?
-Remer, Frederic; Update on confidentiality issues in practice with children: Ethics risk management; Children & Schools; Apr 2005; Vol. 27; Issue 2

Personal Reflection Exercise #4
The preceding section contained information about medication error in mental health and the implication in primary care.  Write one case study example regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Leroy, H., Dierynck, B., Anseel, F., Simons, T., Halbesleben, J. R. B., McCaughey, D., Savage, G. T., & Sels, L. (2012). Behavioral integrity for safety, priority of safety, psychological safety, and patient safety: A team-level study. Journal of Applied Psychology, 97(6), 1273–1281. 

Lustgarten, S. D., & Elhai, J. D. (2018). Technology use in mental health practice and research: Legal and ethical risks. Clinical Psychology: Science and Practice, 25(2), Article e12234.

Rigg, T. (2018). The ethical considerations of storing client information online. Professional Psychology: Research and Practice, 49(5-6), 332–335.

Shahidullah, J. D., Hostutler, C. A., & Forman, S. G. (2019). Ethical considerations in medication-related roles for pediatric primary care psychologists. Clinical Practice in Pediatric Psychology, 7(4), 405–416.

Tyson, P., Law, C., Reed, S., Johnsey, E., Aruna, O., & Hall, S. (2016). Preventing suicide and self-harm: Evaluating the efficacy of a helpline from a service user and helpline worker perspective. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 37(5), 353–360.

Ware, J. N., & Dillman Taylor, D. (2014). Concerns about confidentiality: The application of ethical decision-making within group play therapy. International Journal of Play Therapy, 23(3), 173–186.

What are three confidentiality boundaries to consider when treating self-harming clients? Record the letter of the correct answer the CE Test

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