we believe that it will be required reading our services (or participate in our research) door) with client consent,
nt consent, (second door)
in many psychology training programs, and
rightly so.
REFERENCES
American Psychological Association. (2002).
Ethical principles of psychologists and code
of conduct. American Psychologist, 57, 1060 –
1073.
Behnke, S. (2004, September). Ethics rounds:
Disclosures of confidential information under
the new APA Ethics Code: A process for
deciding when, and how. Monitor on Psychol-
ogy, 35(8), 78 –79.
Fisher, M. A. (2008). Protecting confidentiality
rights: The need for an ethical practice model.
American Psychologist, 63, 1–13.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Meer, D., & VandeCreek, L. (2002). Cultural
This document is copyrighted by the American Psychological Association or one of its allied publishers.
considerations in release of information. Eth-
ics & Behavior, 12, 143–156.
Pettifor, J. L., & Sawchuk, T. R. (2006). Psy-
chologists’ perceptions of ethically troubling
incidents across international borders. Inter-
national Journal of Psychology, 41, 216 –225.
Correspondence concerning this comment
should be addressed to Randolph B. Pipes, De-
partment of Counseling and Counseling Psy-
chology, Auburn University, Auburn, AL 36849.
DOI: 10.1037/0003-066X.63.7.624
Clarifying Confidentiality
With the Ethical
Practice Model
Mary Alice Fisher
The Center for Ethical Practice, Inc.
The important issues raised by Pipes, Blev-
ens, and Kluck (2008, this issue) illustrate
the complications that can arise in discuss-
ing confidentiality and making decisions
about it:
First, they noted that the term client
consent is used by psychologists to mean
two quite different things about confiden-
tiality: (a) acknowledgement of its limits
and (b) consent to disclose specific infor-
mation. They suggested that only the latter
should be called consent.
I agree that it would be misleading to
call an acknowledgement of limits a con-
sent. At intake, what psychologists need
from a prospective client is not only an
acknowledgement but an acceptance of the
exceptions they may make to confidential-
ity. Obtaining informed consent requires
making sure that the client both under-
stands (i.e., is informed about) confidenti-
ality’s limits and consents to accept them.
Thus, in Step II of the ethical practice
model (Fisher, 2008), as part of obtaining
the prospective client’s consent to receive
624
we obtain an initial general consent—con-
sent in advance for disclosures we might
make later.
The second stage of consent about
confidentiality (at Step III of the model)
involves client-specific consent for disclo-
sures not listed among the general limits of
confidentiality that apply to all clients.
During treatment, for example, psycholo-
gists obtain clients’ written consent for dis-
closures needed in their own case (e.g., for
conversation with a family member or for
release of a report).
In the ethical practice model (Fisher,
2008), the term consent therefore means
exactly what it says in both Step II and Step
III. The American Psychological Associa-
tion (APA) Ethics Code (APA, 2002) also
uses that term in both contexts: Psycholo-
gists must begin with an “informed con-
sent” conversation about the limits of con-
fidentiality (e.g., see Ethical Standards
8.02, Informed Consent to Research, p.
1069; 9.03, Informed Consent in Assess-
ments, p. 1071; and 10.01, Informed Con-
sent to Therapy, p. 1072); and they may
disclose information at any time by obtain-
ing the client’s “appropriate consent” (see
Ethical Standard 4.05, Disclosures, p.
1066).
Pipes et al. (2008) objected that Step
II (at intake) does not involve “true con-
sent” (p. 623) because it represents only
“acknowledgement of the limits of confi-
dentiality” (p. 623), not “voluntary or even
proactive agreement” (p. 623). This de-
scription does fit psychologists’ legal obli-
gation under the Health Insurance Portabil-
ity and Accountability Act (HIPAA),
which requires only that the prospective
client sign the Notice of Privacy Practices
to document that it was received. This in-
volves only the providing of information,
not the obtaining of consent. In contrast,
the APA Ethics Code (APA, 2002) and the
ethical practice model (Fisher, 2008) re-
quire “true” informed consent, and that ex-
plicitly protects voluntariness. Once in-
formed about the confidentiality risks,
clients willing to receive our services give
us consent to proceed; and voluntariness is
protected because they are free to give “in-
formed refusal” of services instead. Volun-
tariness is lost only if we obtain “unin-
formed consent”— consent from clients not
adequately informed about the risks.
Second, Pipes et al. (2008) made sev-
eral comments about laws, one of which
referred to Behnke’s (2004) “doors”
model. I endorse his metaphor as a useful
reminder that APA Ethical Standard 4.05
(Disclosures) allows information to leave
the room in only three circumstances: (first
when mandated by law, or (third door)
when allowed by law for a valid purpose.
However, my personal position is more
client protective: I believe the third door
should remain closed; I do not believe a
disclosure suddenly becomes ethical the
moment our legislators deem it legal.
Therefore, Step III (Rule A) of the ethical
practice model suggests that, unless legally
unavoidable, we should do our best not to
disclose without consent.
Note that psychologists have two op-
portunities to obtain the client consent that
I advocate: at intake (Step II) or at the time
of disclosure (Step III). If, in advance, we
weigh the competing interests (e.g., client
confidentiality vs. societal interests) and
decide which circumstances we personally
believe create a valid purpose for disclo-
sure (Step I, Preparation), we can include
those among the “limits of confidentiality”
to be discussed in the initial informed con-
sent conversation (Step II). If such a cir-
cumstance arises later, we are free to dis-
close, not because that disclosure is
allowed by law, but because we had al-
ready obtained the informed client’s con-
sent. Note also that the APA Ethics Code
(APA, 2002, p. 1066) permits disclosure
without client consent when “permitted by
law for a valid purpose,” but it does not
require it. (For this I am especially grate-
ful, since my own state’s privacy law
allows approximately 40 exceptions to con-
fidentiality, not to mention the unreason-
ably broad exceptions legally allowed by
the federal HIPAA regulations.)
Pipes et al. (2008) found it “a little
inconsistent” (p. 623) that I criticized the
use of legal arguments as the foundation
for thinking about confidentiality yet sug-
gested that one may breach confidentiality
if the legal system demands it. The ethical
practice model (Fisher, 2008) is ethics
based in the sense that it is constructed
from our profession’s ethical standards, not
structured around laws. But no such model
would be complete or useful if it ignored
the fact that laws can limit our ability to
protect confidences. Like the Ethics Code,
the model allows disclosure when “man-
dated by law”; otherwise, all psychologists
would be ethically required to engage in
civil disobedience whenever faced with a
legal demand for disclosure. But the model
advocates that we respond ethically to the
existence of such laws. Instead of lightly
breaching confidentiality, we can learn to
use the laws that protect it (Step I), advise
clients about laws that limit it (Step II), and
then limit disclosure to the extent legally
possible (Steps III and IV).
October 2008 ● American Psychologist
 “If psychologists wish to redeem con-
fidentiality from the clutches of the legal
system . . . shouldn’t we at least give equal
weight to principled arguments about po-
tentially higher ethical commitments (per-
haps, for example, saving the lives of many
people)?” (Pipes et al., 2008, p. 623). I do
emphatically advocate such weighing, and
I agree that psychologists’ own values
should be placed on the scales. Others have
discussed the weight that should be given
to confidentiality in this balancing process
(Donner, VandeCreek, Gonsiorek, & Fisher,
2008) and have provided a process for
placing one’s own values on the scale when
weighing competing interests (Knapp, Gott-
lieb, Berman, & Handelsman, 2007). In the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
ethical practice model, Step I (Preparation)
This document is copyrighted by the American Psychological Association or one of its allied publishers.
includes the ongoing task of clarifying
one’s own ethical and moral position about
confidentiality. After September 11, 2001,
some clinicians revisited the weighing pro-
cess and decided to expand the limits they
placed on confidentiality. To their previous
statement about breaching confidentiality
when a client threatened to harm others,
they now added at intake, “and I also re-
serve the right to breach confidentiality if
you tell me someone else plans to kill oth-
ers.” As required by Ethical Standard 4.02b
(and Step II, Rule D of the model), they
also informed existing clients about this
change.
Third, Pipes et al. (2008) elicited my
personal thoughts about the current APA
Ethics Code (APA, 2002). Here I mention
only Ethical Standard 4.05 (Disclosures):
(1) We should retain the phrase “as man-
dated by law” (p. 1066) as an exception to
confidentiality. To delete it would mean
that psychologists would be ethically re-
quired to disobey reporting laws and refuse
court orders. We should applaud the cour-
age of psychologists who incur the risks of
civil disobedience in order to protect their
clients’ confidences, and the profession
should find ways of supporting them in that
decision; but the Ethics Code should not
require that psychologists take such legal
risks. (2) To reduce the resulting risk to
clients, we should (a) remove the exception
“where permitted by law” (p. 1066), (b)
require that psychologists at least take steps
to resolve the conflict when laws mandate
disclosure, and (c) more clearly identify
October 2008 ● American Psychologist
“client consent” as the rule, separating it
from its exceptions. My rationale for (a) is
described above. My rationale for (b) is
that, when faced with legal demands, we
should live up to Ethical Standard 1.02
(Conflicts Between Ethics and Law, Regu-
lations, or Other Governing Legal Author-
ity); so unless the client is perfectly willing
to disclose, we should protect confidential
information to the extent legally possible.
Finally, concerning (c), Ethical Standard
4.05a could be slightly reworded to begin,
“Ordinarily, psychologists may disclose
confidential information only with the ap-
propriate consent . . . ,” to distinguish that
rule from the legal exception in Ethical
Standard 4.05b.
Is my claim really true, that the
“simple” ethical rule has never changed?
Pipes et al. (2008) are correct that I
chronicled changes in the wording of our
“primary obligation.” But it seems im-
possible to make any sense of confiden-
tiality ethics unless we posit an underly-
ing nondisclosure principle that has
remained constant. I phrase it as “Dis-
close nothing without the client’s con-
sent.” This familiar phrase has never ap-
peared in our Ethics Code, but it has been
implied by ethical standards that empha-
sized the importance of obtaining consent
before voluntarily disclosing confidential
information. There have always been ex-
ceptions, and the more numerous they
became, the more they threatened to
overshadow the nondisclosure rule; but I
suggest that it has always been there,
even if only implied. Like the ethical
practice model (Fisher, 2008), the sug-
gestions above are designed to make it less
likely that exceptions will be treated as the
rule.
Fourth, Pipes et al. (2008) suggested
that the model would be strengthened if
one or more sections addressed cultural
considerations. The model itself, like the
Ethics Code, is universally applicable,
leaving psychologists responsible for in-
corporating the ethical issues specific to
their own settings. But in discussing the
model, I should have included cultural con-
siderations, especially as they relate to in-
formed consent (Steps II and III). Cultural
awareness can be important for clarifying
client expectations and for protecting vol-
untariness, especially when obtaining con-
sent for disclosure to family members
(Meer & VandeCreek, 2002). With clients
from other cultures, or for whom English is
not the first language, we must also be
prepared to use interpreters or make appro-
priate referrals (see Ethical Standards 2.01,
Boundaries of Competence; 3.10, Informed
Consent; and 9.03, Informed Consent in
Assessments).
Finally, Pipes et al. (2008) expect the
ethical practice model to be used in psy-
chology training programs. I hope it will
provide the next generation of psycholo-
gists with a clear ethical framework for
considering confidentiality issues. Mean-
while, as in this exchange, it can facilitate
conversation among colleagues not only
about ethical and legal questions but also
about cultural issues, personal values, and
professional standards that affect our ap-
proach to confidentiality.
REFERENCES
American Psychological Association. (2002). Eth-
ical principles of psychologists and code of con-
duct. American Psychologist, 57, 1060 –1073.
Behnke, S. (2004, September). Ethics rounds:
Disclosures of confidential information under
the new APA Ethics Code: A process for
deciding when, and how. Monitor on Psychol-
ogy, 35, 78 –79.
Donner, M. B., VandeCreek, L., Gonsiorek, J. C.
& Fisher, C. B. (2008). Balancing confidenti-
ality: Protecting privacy and protecting the
public. Professional Psychology: Research
and Practice, 39, 369 –376.
Fisher, M. A. (2008). Protecting confidentiality
rights: The need for an ethical practice model.
American Psychologist, 63, 1–13.
Knapp, S., Gottlieb, M., Berman, J., & Handels-
man, M. M. (2007). When laws and ethics
collide: What should psychologists do? Pro-
fessional Psychology: Research and Practice,
38, 54 –59.
Meer, D., & VandeCreek, L. (2002). Cultural
considerations in release of information. Eth-
ics & Behavior, 12, 143–156.
Pipes, R. B., Blevins, T., & Kluck, A. (2008)
Confidentiality, ethics, and informed consent.
American Psychologist, 63, 623– 624.
Correspondence concerning this comment
should be addressed to Mary Alice Fisher, The
Center for Ethical Practice, Inc., 934 East Jef-
ferson Street, Charlottesville, VA 22902.
E-mail: fisher@virginia.edu
625