A client and a therapist walk into an office.
What sounds like a twist on the beginning of an old joke, should
really be the beginning of building lasting trust between client
"Confidentiality is at the core of our profession," said Joy
Krumenacker, a second year student in the Doctor of Psychology (PsyD) program at Carlow University. "People tell us their
deepest, darkest secrets. We need to make sure we are
offering them a safe place, where they can share their secrets and
not be worried that we will break their confidence."
Most times the confidences that are shared between client and
therapist are sacrosanct. Sometimes, however, what the client
relates during therapy can cause the therapist to wrestle with a
difficult ethical or moral dilemma. Criminal activity — be it
drug use, theft, assault, or worse — is often at the center of the
gray area for most therapists.
"Ethical and moral ambiguity is so inherent in counseling," said
Angela Harrington, a first-year student in Carlow's PsyD
program. "I was curious to see how others deal with these
That curiosity spurred Krumenacker and Harrington to become part
of a research project, with Joseph Roberts, PhD, an assistant
professor of psychology at Carlow.
"A solid foundation of knowledge and skills is essential for the
scientifically informed professional practice of psychology, and
Carlow's PsyD program is committed to students advancing the
knowledge in the profession through research as they seek to become
better clinicians," said Robert Reed, PsyD, chair of the Department
of Psychology and Counseling at Carlow, and interim dean of the
Graduate School. "This is one of the bases for accreditation
from the American Psychological Association (APA), and Carlow
was recently awarded the program maximum seven-year
Krumenacker, Harrington, and Dr. Roberts, along with 2010
undergraduate alumna, Vanessa Vudy, and master's of professional
counseling students Jenna Dlugos and Zia Sultan surveyed more than
150 of Pennsylvania's licensed clinicians, exploring what factors
most help them decide when to report criminal activity that comes
to their attention during a counseling session. The research
phase of their study, titled "Peripheral Criminal Activity:
Implications for Practice and Supervision in Mental Health
Settings," is complete, and they are working toward getting their
results published this spring.
"Most forms of criminal behavior are not required to be reported
by a therapist, but how they respond can be the difference between
jeopardizing a therapeutic relationship or not," said
Harrington. "It's often a decision to immediately act versus
not do anything."
A landmark case, Tarasoff vs. Regents of the University of
California, decided by the California Supreme Court in 1974,
held that mental health professionals have a duty to protect
individuals who are being threatened with bodily harm by a
patient. The case, which involved the murder of a female
graduate student, Tatiana Tarasoff, by another graduate
student who had disclosed his intentions to murder Tarasoff to his
therapist several months before. The therapist had not
reported the threat outside of the university, Tarasoff was
murdered, and, when the whole story came out, Tarasoff's family
Thankfully, not every ethical or moral dilemma faced by a mental
health professional involves a threat to murder, but it can still
be quite serious. The study revealed that therapists most
frequently receive a verbal report of child abuse, driving under
the influence, selling drugs (either prescription or street drugs),
child neglect or sexual abuse, shoplifting or theft, and
rape. Therapists who visit clients' homes frequently observe
many of those activities - or evidence of those activities - during
the therapy session.
"In Pennsylvania, mental health professionals are mandated to
report child abuse or neglect," said Dr. Roberts. "Most other
activities are simply not reportable, regardless of a clinician's
value-based reaction to a criminal revelation."
However, the study found that even with suspected child abuse,
consensus of how to act was difficult to attain.
"In a separate study, 144 counseling psychologists could not
reach consensus after reading a vignette of alleged child abuse,"
said Krumenacker. "They tended to examine non-legal factors
in making their decisions, such as: agency or practice
protocols, the level of experience with such cases, effects on the
ongoing counseling relationship, or whether or not the client was
All of which means that if criminal activity is revealed or
observed during a session, it does not make it any less vexing for
the therapist. In fact, many of the situations involve a
conflict between professional ethical standards and personal moral
"If the ethical guidelines aren't in line with your personal
belief system, ethics are often the first things to go," said
Harrington — the implication being that when professional ethics
are sacrificed, consistent, competent therapeutic practice for the
client often suffers.
To address this issue, Krumenacker says that the study
demonstrates several important goals.
"There needs to be a bigger push in all levels and helping
professions around ethics," she said.
"Clearly naming ethical guidelines around certain issues is
important," agreed Harrington, who cited a difference in the
quality and quantity of ethical training among in-home therapists
and office based therapists as a problem to be addressed. "After they've had their ethical training, what does continuing
ethical training look like?
But even under the best of training, Krumenacker and Harrington
acknowledge that gray areas abound in therapeutic practice.
So what should a mental health professional do when in doubt?
"Consult with another colleague," said Krumenacker. "That's huge. Consult, consult, consult."
"And document, document, document," said Harrington.