Susan Lindsay talked to Mary Montaut about the complex Issues of ethics and psychotherapy, including the question of Mandatory Reporting of Sexual Abuse.
I am concerned that a distinction should be made between ethics and the law, and also that a distinction should be made between a Code of Ethics and one’s personal ethical position as a therapist. Sometimes people talk about the Code of Ethics as if it was synonymous with the law and the legal position, and as if it was a law in itself - that the Code of Ethics will solve everything. I am concerned about that, because firstly, a Code of Ethics can’t cover every ethical dilemma, and secondly, there could be times when to be truly ethical would be not to do what the Code of Ethics told one to do. An example of this dilemma would be the case of journalists, who have occasionally gone to prison because of their determination to uphold their confidentiality, despite the courts position I find it quite an interesting question – would you, as a psychotherapist, be prepared to uphold your commitment to confidentiality sufficiently to go to court? Are there any circumstances that would warrant you doing that? That really puts it up to us.
The Nature of Confidentiality
I think sometimes that when we make an agreement with a client, it is not always clear if you’re intending there to be limits to that confidentiality. I am not satisfied that this is always made explicit to the client I feel that once there is a danger that you may need to break a particular client’s confidentiality, my position is to then tell the client so that they arc clear what the limits of the confidentiality are; for example, if what they are going to disclose to you demonstrates that they are a danger to themselves or other people, that you might break the confidentiality. Then the argument may come back that if you know that they are a danger to someone, you should not tell them that you might break confidentiality, because then they won’t tell you. But I feel that is a breach of integrity – to imply that you are going to treat what they tell you in confidence and then not be willing to do so – and it involves taking quite a paternalistic attitude, as if you are claiming to have more moral awareness or whatever, than the client. So I think it s really about the role you’re taking, the therapeutic role, and you need to be clear.
Mandatory Reporting of Sexual Abuse
I am interested in the issue of Mandatory Reporting of Sexual Abuse, and I am concerned about it. I am concerned about it first of all because I have direct evidence already in a small way, that abuse is going underground. Although there is a growing awareness about abuse, people are also becoming more cautious about revealing the fact that they have been abused. They aren’t as clear that there is a safe space where they can do it. I have also heard evidence of instances where somebody who may have begun to abuse has been unable to go for help, which might have prevented them becoming an established abuser, for fear that the minute they mention that they might have been abusive, their confidence will not be honoured and that they would be sent for some kind of punitive action and that all kinds of bodies would become involved. And I have also had clients who thought that they had been abusers, but actually they had never been abusers. Rather they had, as so many young children do, taken part as a child with other children in sexual play; and now they are adult they fear, with all the talk about abuse, that they were guilty of being an abuser. This is a horrific, painful thing, and even more painful if you can’t dare to talk about it for fear that you might be reported in some way. In the present climate, undiscovered abusers who may wish for therapeutic help (remember that many of them suffered horrendous abuse in their own childhood), must be very doubtful that a confidential, safe, therapeutic space is available to them. I’m not sure that it is.
The Right to Privacy
And I think there is another issue: I often think what would I do if my own daughter or son came home and told me they had been abused? What kind of medical help would I go for? I would be very reluctant, because I know that as soon as I go for any kind of professional help, the matter will be out of my hands, and the choice of whether my child would have to go for further abusive investigations, which – no matter how carefully done – may add to their distress, is out of their hands and out of my help. The last thing I would want would be to have to struggle with either the police or the medical profession, who have their own agenda about finding the abuser, regardless of my daughter’s or son’s well-being. Now, when I face that dilemma, then I see that, as professionals, we could be putting our clients into the same dilemma. Does a woman who has been raped, not have the right to go for medical or psychological help, without necessarily having to decide beforehand whether she is strong enough or willing enough to take a case against her abuser? How is it that her responsibility to society becomes even greater than her right to have healing and support? I find that is an abuse of her privacy.
A Counter-Transference Issue
There is also an issue of counter-transference here. Sexual abuse at its most basic, is a severe violation of a boundary – of privacy, and of the body. By agreeing to Mandatory Reporting, the therapy is being invaded. Agencies dealing with sexual abuse often find themselves having to spend a great deal of time paying attention to boundaries within their own organization. The privacy assured by confidentiality can be violated. By passing a law on this matter, are we, as a society, simply reflecting the abuse and repeating it?
Protection for the Victim
I certainly think that psychotherapeutic or medical help might include discussion with a victim about reporting her situation and about taking it further; but pressure to do so – whose interests are we taking care of here? I think this is where you have to balance up the interests of the individual and the society at large. But why must the interests of society be protected by victims, I mean people who have just been hurt, rather than others? I don’t find that a very ethical position. And when the victim is not a woman who has been raped, or a man who has been raped, but a child - then it seems to me even more important, that as a parent or a professional we should be advocating most strongly the protection of that child. The argument for Mandatory Reporting is that the protection for that child will come by protecting other children – which is right, the abuser must be found – but the argument for protecting the particular child, would be not to expose her to any more molestation or violation of her privacy, which necessary medical examinations must include, no matter how sensitively carried out. I am afraid that there is clear evidence that much of the investigation that goes on in these cases is not sensitively carried out: we don’t train people adequately, and we are not willing to give the funds and resources necessary to have a proper service. So it seems to me that Mandatory Reporting would only make it look as if we are doing something. My greatest worry is that it would be politically very expedient for a government to bring in Mandatory – Reporting, because all it requires is putting in place a law, for which they would get a lot of plaudits for taking care of victims of abusers; but in fact it would only serve to cover up all the inadequacies. Already we do not have enough resources for people who are being traumatised by abuse – we have children living in bed-and- breakfasts, whom the Health Boards know full well are being abused on the streets and used in prostitution. They are not being protected. At present when therapists do break confidence and report an incident, it is very often not followed up and taken seriously enough, and so it’s ludicrous to suggest that passing a law on Mandatory Reporting would solve anything at the moment.
Now having said that, as a therapist I think it is ethically required of me, if I know that abuse is going on, particularly of a child, and if I know that there is an abuser at large, to do everything I can to bring it to the attention of the proper authorities. I must be free to break confidentiality in this instance because somebody is being damaged, and other people may be damaged. But at the same time, I have to have some leeway about exercising that ethical judgement. I think it is right that I am required to make a judgement very thoughtfully and to do it with an awareness of what the legal position is and what the needs of my client and other people are. I may have to break confidentiality and I may even have to break my word, which is another ethical dilemma. But although in many instances I would be required to do that. I think that there are exceptions.
I find it really horrific when I hear from colleagues that, because of the requirements of their agencies, they have to report an incidence of abuse reported by a child, even when they are ninety per-cent certain at the time that it would turn out to be a false allegation. There are huge consequences for other people, including loss of job, loss of good name, loss of well-being, poor treatment, poor handling by the police and the agency concerned. People’s lives can be seriously disrupted and disturbed over a period of many years. False allegations have been made. People having to report them can know at the time that this will be a red herring, yet much harm, distress, waste of public resources and time can be caused. And the actual child making the allegation in the first place suffers greatly through feeling guilty about the consequences of their actions, that nobody could bring home to them at the time because it would be seen as interfering with the evidence and trying to stop the child from reporting an allegation. These are not simple issues and they are talked about far too simplistically a lot of the time.
I am also disturbed in the fact that different legal advice seems to be given to different agencies and different therapists. It seems to me that some of the Rape Crisis Centres believe, and have been told, that legally they are required to report any instance of abuse. I have first-hand evidence of some clients refusing to go to Rape Crisis Centres because they say they have been told on the phone that if they give the name of their abuser during therapy, intentionally or accidentally, it will have to be reported – so they can’t risk it. I find it annoying that agencies which were set up for the support of victims are no longer available in that way. Of course, that is not to say that they don’t do good work and that people don’t get help from them, but I think that above all we need a sale space for victims. There must be some place where people can talk about what has happened to them with no fear of further repercussions unless or until they are ready to deal with them. I am aware of the argument that wherever Mandatory Reporting of Abuse has come in, there has been a rapid decrease in abuse. How ever, I am not clear whether there has really been a rapid decrease in abuse or whether there has been a rapid decrease in reporting of abuse There is a great fear of the latter.
The Interests of the Victim
I think there is a need to protect people, but the law and the Code of Ethics have to cover a general situation. The danger is that you as a therapist or a member of a helping profession have to deal with the specific, and they do not always coincide. Maybe there is a case for mandatory reporting by some agencies, but I would make a strong case for therapists to be excluded. I would also make a strong case that therapists would be required to demonstrate that they have seriously considered the need to break confidentiality wherever anyone is at ongoing risk – that they discuss it with their supervisor, that they are aware of what the issues are. But I think that is quite different from saying that in every circumstance you must break confidentiality, even if it is not in the interests of the client or whoever has been abused, because it can be against the interests of the victim.
The Therapist’s Own Integrity
I have also heard about adult clients who are still being abused in their twenties, and who put the therapist in a terrible dilemma of whether or not to report this abuse, because it is really obvious that the client will disappear the minute that there is any question of the abuse being reported. So which is the more ethically correct position that you stay with the client, supporting them through the horrors of it, and eventually hopefully to getting out of the situation and perhaps disclosing it; or that you report it, and the client loses all support, probably denies the abuse and then suffers further abuse, but won’t come back for any kind of help because you have intimated that you are going to report it? If there is Mandatory Reporting, what should be the ethical position of therapists – to go with the Mandatory Reporting, or to break the law and support the ethical need to heal and be there as a therapist and trust the confidentiality of their client? I think when we are dealing with ethics, we have to be aware of our own integrity, and the values out of which we are coming. We must think ethically, whether the issues are covered in the Code of Ethics or not, and we have to apply our Code of Ethics in an ethical way. At the same time, we have to take into account what the legal situation is, and our obligation to society to uphold the law (which in theory at least is there for the benefit of the majority of citizens), but at the same time to do that with awareness. We should not do it with a transferential mind of a child who believes that the authority, teacher, parent, judge, law, is necessarily always right. The actual question of what is right goes beyond that. Yet these are not decisions it is ethical to make alone – they must be made with reference to a Code of Ethics and with a supervisor’s, and other relevant professional’s, input.
Agents of Social Control?
There are many instances besides the question of Mandatory Reporting of Sexual Abuse where this question of an ethical position for the therapist arises – whether it’s tax evasion, burglary, or more obviously drugs, where somebody who may be a client who is coming off drugs but may have supplied them in the past – should we be reporting that? After all, we know that suppliers of drugs cause great damage to people. And what about people who have been members of illegal organisations – should we immediately be breaking confidentiality in that instance? We may be jeopardizing their journey to come out of it, and out of the traumas that they have suffered in it. So it’s a much wider issue than just the Mandatory Reporting of Sexual Abuse. Further, there are several ethical questions that therapists should be looking at even more closely, about the way we treat issues of abuse. For instance, if a client has an occluded memory which comes to their consciousness, should you support them immediately to believe that this occluded memory has actually happened in fact? Or should you hold the position that, we don’t really know what an occluded memory may or may not mean about what happened in the past; that this is the truth in somebody’s consciousness, but that it may take time and you may never know whether this sense of memory is a real fact in the world or not. Sometimes I think that therapists jump too quickly one way or another. There are very important questions from social science about whether therapists, social workers, psychologists, and medical people should be agents of social control. It’s a very old argument, whether the helping professions are agents of social control, or are there for supporting the individual. There is a real danger at the moment that therapists are moving towards becoming agents of social control.
Accepting the Person
As a therapist, I certainly prefer to be in the position of supporting the individual to make their own judgements, to look at their own values, to look at where they are coming from. I feel that there is a very particular need for the space that therapy can provide for people to be in a non-judgemental space, a free space where they can look at all the issues freely. For therapy to work, it needs to be providing a non-judgemental space, with an acceptance of the individual as a person – that no matter what they have done or who they are, they are important as a person, just by right of being a person. This is a very basic ethical position, a basic humanistic position. That is not to condone people who murder or paedophiles or anybody else, but it is to say that they are more than their actions. An essential part of therapy and the therapeutic relationship is the confrontation that is required of clients about their actions. But it is a confrontation which says, look at this, look at the consequences, look at how you are harming people, look at your denial about it, rather than a confrontation that says you are a bad person.
Code of Ethics.
I think that mental health professionals should be obliged by society to make some judgements. I think it is right that we should be obliged to take it very seriously wherever we are aware that people are severely damaging or hurting other people, and I think that we should be obliged to take care. That is what our Code of Ethics does, it says you must pay attention; if you decide not to do something about it you must account for the fact that you are not breaking confidentiality. That is why in some circumstances, we are allowed to break confidentiality – but we need to do it advisedly, we need to do it cautiously, we need to be very aware of what we are doing and to use wisdom in it.
Susan Lindsay works as a therapist with Connect Associates, Blackrock, Co Dublin and as a trainer at the Institute of Creative Counselling in Dun Laoghaire, and is author of The Love Crucible (Marino, 1995).