Ethics Consult: Balancing Safety and Confidentiality

Dear Ethics Consult, 

I have an adult client who has shared with me that their parent, with whom they live, often drives while under the influence of alcohol in our town. We have discussed harm reduction strategies such as taking the parent’s keys away, but so far these strategies have not been successful. What, if anything, can or should be done to minimize the risk to this parent as well as everyone else in town?

– Trying to Keep Everyone Safe

What Is a Therapist’s Ethical Responsibility When a Client Shares About a Parent Driving While Intoxicated?

Dear Keeping Everyone Safe, 

Credit to you for looking at the big picture and identifying that as therapists, our ethical considerations extend beyond just our client’s own interests. 

First, it’s useful to take stock of your personal values and reactions. The knowledge that someone might be driving intoxicated on shared roads is unsettling. These types of dilemmas trigger moral emotions, urging us to take action. Luckily, it sounds like you’re facing an issue that is alarming but not emergent, so there’s time to reflect. Notice your immediate impulses and beliefs about the issue, any attitudes towards people who drive intoxicated, about adult children parenting their parents, and any related emotions arising. 

If we aren’t in touch with our own moral landscape, it creates clinical and ethical weak spots. The preference for closure on an issue can push us to seek confirmation, instead of consultation, or to make hasty conclusions. Allowing time to reflect and intentionally remaining open promotes more nuanced, integrative solutions.

I like the four bin approach for analyzing complex situations like this, because it allows you to divvy out the clinical, ethical, and legal and risk management aspects. 

Clinically speaking, perhaps this is an important life challenge and opportunity for your client to clarify what’s actually within their control, to define their role as an adult child, and to receive therapeutic support that enables them to act skillfully and consistently with their values. 

For the risk management and legal aspects, consulting with your liability insurance and/or attorney is a good idea. They’ll know your state’s reporting laws and recommend that you document areas like: recognition of the dilemma, factors you weighed (e.g. Duty to Protect), the rationale for your response, etc.

Now to the ethics question. Our professional ethics codes cite principles like beneficence/non-maleficence, dignity/worth, and confidentiality standards that are important to consider here.

For example, the NASW code notes that social workers “seek to resolve conflicts between clients’ interests and the broader society’s interests in a socially responsible manner.” While important to be aware of, these guidelines don’t offer prescriptive advice for your situation.

You might be simultaneously feeling pulled into acting as an agent for your client’s welfare, for their parent, and the protection of the public. The threshold for reporting health or safety threats can be a gray area, necessitating a judgment call based on the specific factors at play. This gets complicated, because we often receive our information secondhand and without pertinent details for accurately assessing risk.  

Then, how do you harmonize competing interests?

Unilaterally taking action would usurp your client’s autonomy and may violate confidentiality agreements. With few exceptions (like any mandated reporting requirements), you have an obligation to hold your client’s confidentiality as primary.

Similarly, pressuring your client on the right thing to do is fraught. Instead, what will foster a supportive context where your client can grapple with their own uncertainty in a way that honors their autonomy? 

Review Confidentiality Agreements With Your Client

It’s also a good time to review confidentiality agreements with your client. This happens at intake, but most clients aren’t thinking about the contract in the midst of a stressful situation. Here, concrete explanations help. You can say something like, “At this point I won’t breach your confidentiality without your consent, but if risk increases, like driving intoxicated with minors on board, I may need to.”

This conversation models your process for making difficult, principled-based decisions and the capacity to endure painful consequences in relationships when appropriate.

 You mentioned that hiding the keys didn’t work, and I suspect you’ve alerted your client to community referrals for the parent without success. So, let’s imagine that after your client has explored potential implications, they decide to contact the police or some other intermediary. You’ve provided consultation, encouraged deliberate, moral decision-making and supported their autonomy. You can reflect on the outcomes and document the situation.

The tougher circumstance may be if your client decides not to take further action, exercising their right to have the disclosure held in confidence. This leaves you holding secondhand information about a presumed safety risk.

For this scenario, breaking confidentiality has the strong potential to result in negative consequences for your therapeutic relationship, for the client, and possibly their parent. Given that anticipated harm, intervening against your client’s wishes—without a clear, immediate threat—is harder to ethically justify. If you so strongly disagree with your client’s refusal that it’s impeding treatment, you might explore therapeutically transferring care.  

Finally, it’s helpful to have a practice of reflecting on your process and addressing any excessive responsibility-taking, self-care needs, etc. for your own peace of mind.  As therapists, we’re challenged with the ethical tensions of providing care and the moral dilemmas of our clients. However, we’re also uniquely equipped with the expertise to translate big feelings into actionable ideas. This gift allows us to support our clients in navigating an ever-complicated, polarized world. We can use these opportunities to root into our professional values and cultivate creative solutions for the greater good. 

Sending moral support,

Ashley

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