Dr. Jennifer Melfi: What line of work are you in?Client confidentiality in psychotherapy only goes so far. If a client threatens the therapist, another person, or themselves, and the threat is perceived as serious, then most jurisdictions (including the BPS ethics code) recognise this as a valid reason to breach the client's privacy and go to the authorities. But what about the situation in which the client confesses to a past violent act for which they were never prosecuted? What if they tell their therapist that they've previously murdered someone?
Tony Soprano: Waste management consultant.
Steven Walfish and his colleagues have investigated this issue in a survey of 162 US psychological psychotherapists recruited randomly via the National Register of Health Service Providers. Astoundingly, 21 of the psychologists said that on at least one occasion they'd had a client disclose in therapy that they'd murdered someone, but never been found out (one unlucky psychologist said they'd encountered this scenario six times!).
One hundred and three of the psychologists said they'd had a client disclose having committed an act of previously unreported sexual assault, and 111 of them had had a client disclose a previously unreported act of physical assault. The majority of psychologists said disclosure of past physical assault had happened on three or more occasions; one of them said it had happened more than 200 times!
From an ethical point of view these disclosures of past violent acts are trickier to resolve than threats of future violence, especially if there's no other reason to believe that the client remains a threat. Among the psychologists surveyed in the current research, the majority (63.2 per cent) said such disclosures had had a neutral effect on therapy, 18.8 percent said it was harmful to therapy and a similar proportion (17.9 per cent) viewed it as beneficial.
From a therapeutic perspective, the researchers pointed out that those therapists who viewed the disclosure negatively were at obvious risk of 'negative counter-transference'. This is a fancy way of saying that the disclosure could negatively affect the way the therapist relates to their client, especially if the therapist has themselves previously been a victim of violence. Psychotherapists could be trained to guard against this, but Walfish and his colleagues point out that it's not unusual for therapists to be attacked or threatened by clients and so: 'fears of potential client violence may not always represent an unresolved conflict on the part of the therapist. The psychotherapist knowing this piece of clinical information [the disclosure about past violence], and knowing that the best predictor of future behaviour is past behaviour, may be concerned that they themselves may become a victim of violence.'
Somewhat worryingly, nearly one fifth of the current sample did not feel fully informed about what to do when a client makes a disclosure about past acts of violence, and nearly two thirds felt inadequately prepared for the situation by their graduate training.
Walfish and his colleagues concluded that therapists need to be prepared to hear any material in their consulting rooms, 'regardless of how unusual or unpleasant.' They also need to be aware of their own emotional reactions to disclosures of past violence, how to maintain their own safety, as well as their legal and ethical obligations. 'Graduate training programmes, internship and postdoctoral training settings, and continuing education courses should be encouraged to explore this often difficult topic area in greater depth,' the researchers said.
Walfish, S., Barnett, J., Marlyere, K., and Zielke, R. (2010). “Doc, There's Something I Have To Tell You”: Patient Disclosure to Their Psychotherapist of Unprosecuted Murder and Other Violence. Ethics and Behavior, 20 (5), 311-323 DOI: 10.1080/10508422.2010.491743 [ht: Ian Leslie]
A further note on the BPS Ethics Code: The code emphasises the importance of peer support and supervision. If you are a psychologist and unsure how to proceed following a client disclosure, you should seek guidance from your peers and supervisor, fully evaluate the situation, consider alternative courses of action and fully document the process of decision making [thanks to Dr Lisa Morrison Coulthard for this advice]