Copyright 1983 by the American ! igical Association, Inc. i7/83/3002-0245$00.75 Breach of Confidentiality and Perceived Trustworthiness of Counselors Thomas V. Merluzzi University of Notre Dame Cheryl S. Brischetto Oregon Health Sciences University This study investigated the impact of breaching confidentiality on perceptions of counselor trustworthiness. Subjects heard audiotaped counselor-client in- teractions that culminated in a decision by the counselor to breach or maintain confidentiality. In a control condition no confidentiality manipulation was presented. The degree of seriousness of the client's problem was manipulated in addition to the level of counselor experience, type of presenting problem, and counselor. Two hundred male undergraduates were randomly assigned to one of 48 cells defined by a 3 (confidentiality: confidential, nonconfidential or control) X 2 (problem seriousness: highly or moderately serious) X 2 (counselor experience: expert or nonexpert) X 2 (presenting problem: sui- cide or drug abuse) X 2 (counselor: A or B) between-subjects factorial design. Among other measures subjects rated counselors on trustworthiness. A Con- fidentiality X Problem Seriousness Interaction indicated that with highly seri- ous client problems breaching confidentiality was associated with significantly lower trustworthiness ratings compared to all other conditions. The implica- tions of these results and other findings are discussed. In his initial conceptualization of coun- seling as an interpersonal influence process, Strong (1968) suggested two consequences of trustworthy behavior; first, it would en- hance the client's divulgence of personally damaging material, and second, it would enhance the extent to which the counselor can influence the client. Further, Strong indicated that the counselor can be perceived as trustworthy by "paying close attention to the client's statements and other behavior, by communicating concern for the client's welfare, by avoiding statements indicating exhibitionism or perverted curiosity, and by assuring confidentiality of all transactions" (Strong, 1968, p. 222; emphasis added). Two recent reviews of the literature have emphasized the need for research on trust- worthiness in counseling relationships, (Corrigan, Dell, Lewis, & Schmidt, 1980; Heppner & Dixon, 1981). In the studies The authors wish to thank Mark Rodrigues and Stan Hoffman for portraying the counselors. Also, we would like to acknowledge Morgan Griffith's invaluable con- tribution to data collection and reduction in this study. Requests for reprints should be sent to Thomas V. Merluzzi, Department of Psychology, University of Notre Dame, Notre Dame, Indiana, 46556. reviewed by Corrigan et al. (1980) and Heppner and Dixon (1981), and in subse- quent studies (LaFromboise & Dixon, 1981; Rothmeier & Dixon, 1980), a number of verbal and nonverbal cues were used to dis- tinguish trustworthy and untrustworthy counselor behaviors. Although these stud- ies, in general, did establish a number of behaviors that were indicative of untrust- worthy counselor demeanor, the behaviors used to create role descriptions of untrust- worthy counselors were numerous and ex- treme and not likely to represent an actual counseling situation. In contrast, during actual clinical practice, counselors who may be empathic and helpful often struggle with the problem of confidentiality and its effect on trustworthiness in the counseling rela- tionship. In addition, the most recently promulgated APA Ethical Principles for Psychologists emphasize thai exceptions to confidentiality must be made if clients present danger to themselves or others (American Psychological Association, 1981). In some instances the judgment to breach confidentiality is clear, evident, and neces- sary for the welfare of the clientin other instances it is more equivocal. However, overall, the Principles do not provide the psychologist with a clear set of guidelines 245 246 THOMAS V. MERLUZZI AND CHERYL S. BRISCHETTO concerning when information can be re- leased. Thus, whereas the research on trustwor- thiness has focused on a number of extreme behaviors and situations to define "un- trustworthy counselor behavior," breach of confidentiality (and limits on confidential- ity) may actually occur more often in more typical situations, in which the counselor is generally acting in an empathic, helpful, and trustworthy manner. In those situations, breaching confidentiality may be a difficult decision for the therapist. In fact, the APA Ethical Principles suggest that review of the case with professional colleagues and serious deliberation are in order in cases in which breach of confidentiality is considered. This study attempted to investigate the impact of breaching confidentiality on per- ceived trustworthiness of counselors con- ducting initial interviews. The decision, on the part of the counselor, to maintain or breach confidentiality was presented as a serious issue that required much delibera- tion. Moreover, the audiotaped interchange between the counselor and client presented the counselor as an empathic, caring person. In addition, in order to determine if the de- gree of experience of the counselor would affect the perceptions of trustworthiness, counselors were presented as either "expert" or "nonexpert." Finally, one might assume that breaching confidentiality would occur more frequently in situations in which the client's problems were very serious. For the sake of comparison the level of seriousness of the client's problem was manipulated to study the effects of breaching confidentiality on trustworthiness as a function of the seri- ousness of the presenting problem. Method Subjects and Design Subjects were 200 male undergraduates from a pri- vate midwestern university (ages 18-21) who were en- rolled in Introduction to Psychology and received course credit for their participation in the experiment. Subjects were run prior to the section of the course that covers therapy. Therefore, they were not all system- atically exposed to the practice of confidentiality. In addition, because they were mostly freshman and sophomores, they had not taken any additional course work in psychology that would have sensitized them to the issues of confidentiality. Finally, although some may have received previous counseling services, fresh- man and sophomores, are the least served by the uni- versity counseling center. Therefore, the population in this study was considered to be no more sophisticated vis-a-vis confidentiality than any other sample in that age group. Subjects were randomly assigned to one of 48 conditions with no less than four subjects in each condition. The study was a 3 (confidentiality: confi- dential, nonconfidential, or control) X 2 (problem se- riousness: highly serious or moderately serious) X 2 (counselor experience: expert or nonexpert) X 2 (pre- senting problem: suicide or drug abuse) X 2 (counselor: Counselor A or Counselor B) between-subjects de- sign. Independent Variables Confidentiality. Following an audiotaped dialogue between a client and counselor, the counselor was por- trayed as being alone in his office and thinking aloud about the interview. The following statement was then spoken by the counselor: "This person has a problem; he seems embarassed about it and was hesitant to come for help." Then, one of two confidentiality manipula- tions was presented as the conclusion to the counselor's thoughts. In the nonconfidential condition the counselor said "I think it's important that I notify this person's family about this situation." In the confi- dential condition the counselor concluded by saying "I think it's important that I not mention this situation to this person's family." For the control condition, after the dialogue between the client and counselor was completed, there was no statement made by the coun : selor. Problem seriousness and type of presenting problem. Individual scripts 1 of clients-counselor interactions were developed for each of two presenting problems (suicide and drug abuse) and two levels of problem seriousness (highly serious and moderately serious). The dialogues in each of the scripts were kept as similar as possible except for variations that reflected the different pre- senting problems and levels of problem seriousness. Thus, a script presenting a moderately serious problem was developed and adapted to reflect concerns related to suicide and drug abuse. That script was also adapted to present a serious suicide or drug abuse problem. Two second-year male doctoral students in counsel- ing psychology portrayed the counselors, and a second- year law student portrayed the client on the audiotapes. They were all given the scripts in advance and practiced extensively prior to the taping session. With the con- fidentiality manipulations deleted, the audiotapes were subjected to pilot testing to determine if any differences occurred between counselors. In the pilot study 64 undergraduates, who received experimental credit, were randomly assigned to one of 8 conditions defined by two levels of problem seriousness (serious vs. nonserious), two presenting problems (suicide vs. drug abuse) and two counselors (A vs. B). Thus, the pilot was a 2 X 2 X 2 between-subjects factorial design. The Expertness, Attractiveness, and Trustworthiness scales of the Counselor Rating Form (see Dependent Measures 1 Copies of the counselor-client interactions are available from the first author. CONFIDENTIALITY AND TRUSTWORTHINESS 247 section) yielded no main effects or interactions. Therefore, the counselors' behavior in all the tapes was comparable and did not vary as a function of presenting problem or problem seriousness. Experience level. The level of experience of the counselor was manipulated by written introductions. Prior to listening to the audiotaped interview described above, subjects read a description (reproduced below) of the counselor that portrayed him as either expert or nonexpert. < Expert Introduction The counselor you will be hearing has received his PhD in counseling psychology. He has had exten- sive training and experience as a professional coun- selor and has published a book, Innovative Tech- niques in Counseling. He is presently on the staff of a university counseling center. Nonexpert Introduction The counselor you will be hearing is currently a first-year trainee in a doctoral program in counsel- ing psychology. He received his BA in psychology a year ago. He has recently completed a course in counseling theory and practice. Procedure Prior to hearing the audiotape, subjects were in- formed that one purpose of the experiment was to assess the decision making abilities of counselors. They were also told that the dialogue they were about to hear was taken from an actual counseling session in the university counseling center. The subjects were encouraged to try to assume the client's role and to see the problem from the client's perspective. Next, they read the written introduction that described the counselor as either ex- pert or nonexpert. Then, depending on the condition to which the subjects were assigned they read one of the four following descriptions of the client. Serious Suicide Problem You are a 21-year-old male who has come to the uni- versity counseling center because you have been very depressed. You have, in the past, made re- peated attempts to take your life and you were also hospitalized for severe depression. You find your- self now, again, in a similar-situation with similar feelings. You cry a lot and are seriously thinking of taking your life. Serious Drug Problem You are a 21-year-old male who has come to the uni- versity counseling center because you believe that you are a heroin addict and you are desperate. You are physically and mentally a wreck. Getting the next fix is what's on your mind. You are into steal- ing to finance your habit. Recently, you had a close call with death from taking some bad stuff someone sold you on campus. You have been hallucinating a lot. You almost killed yourself and someone else while driving your car. Moderately Serious Suicide Problem You are a 21-year-old male who has come to the uni- versity counseling center because you have been feeing a little blue lately. You feel like nobody ap- preciates you; neither friends nor family. Some- times when things are going well you feel like life is okay. However, there are those other times when , you feel like ending it all. Moderately Serious Drug Problem You are a 21-year-old male who has come to the uni- versity counseling center because you are feeling kind of out of it. You have been smoking grass fre- quently and have been feeling kind of indifferent toward everything and everyone. In the conditions in which confidentiality was ma- nipulated the client descriptions for all problems in- cluded the following concluding paragraph: You have resisted coming to talk to anyone because you are ashamed and don't want others to know things are bothering you. Imagine yourself seeing a counselor and the following dialogue occurring be- tween the two of you. After the dialogue there will be a pause on the tape. The end of the pause will signify the end of the interview segment and the counselor will then be alone in his office thinking aloud about something directly related to the inter- view. This last paragraph was altered in the control con- dition. The following statement replaced the last sentence: "The end of this pause will signify the end of the interview." After reading one of these client de- scriptions the appropriate audiotaped interview was played twice for the subjects so that they might adopt more effectively the client's perspective and hear the confidentiality manipulation. After listening to the counselor-client interaction they completed several rating forms and were debriefed and dismissed. Dependent Measures The Counselor Rating Form (CRF; Barak & La- Crosse, 1975) was used to measure the subjects' per- ceptions of trustworthiness. The CRF contains 36 pairs of bipolar adjectives that assess the dimension of counselor expertness, social attractiveness and trust- worthiness. The authors report split-half reliabilities of .87.85, and .90 for the three dimensions, respectively (LaCrosse & Barak, 1976). Although the trustworthi- ness scale was of primary interest, the expertness and attractiveness scales were also reported. Subjects also completed several ancillary measures that pertained to the counseling interview. Using a 1-7 scale they rated two questions in each of the following areas: (a) How well did the counselor understand the client's problem? (b) Would the outcome of counseling be positive or negative? and (c) Would you refer an ac- quaintance or a close friend to the counselor? The sum of the ratings of each of the two questions in each area was used in the analysis. Additional questions assessed whether subjects felt that confidentiality should be maintained and to whom, if anyone, information should or could be divulged. Finally, questionnaire items were included to determine if the confidentiality and problem seriousness manipulations were perceived as intended. Subjects were asked to rate on 7-point scales (a) how confidential or nonconfidential was the counselor and (b) how serious was the client's problem. 248 THOMAS V. MERLUZZI AND CHERYL S. BRISCHETTO Results Manipulation Check Measures An Analysis of Variance (ANOVA) on the manipulation check measures revealed sig- nificant main effects for subjects' ratings of how confidential the counselor was, F(2,153) = 168.15, p < .001, and how serious the client's problem was, F(l, 153) = 63.30, p < .001. Thus, the manipulations of confi- dentiality and seriousness were perceived by subjects as intended. The expertness scale of the CRF was used to assess the impact of the experience level manipulations. The analysis of expertness ratings as a function of experience level revealed no significant differences, F(l, 153) = 2.37, p ~ .125, be- tween high experience level counselors (M = 47.94) and low experience level counselors (M = 44.98). Thus, the manipulation of experience level either was not well detected by the subjects or riot a critical variable in the perception of subjects. Counselor and Presenting Problem Based on pilot testing it was anticipated that the effects of counselor and presenting problem would not be significant. However, Counselor B was seen as more expert (M = 48.43) and more attractive (M = 48.90) than Counselor A (M = 43.49; M = 45.05). Also, when counselors discussed suicide problems they were seen as more attractive (M = 49.00) than when discussing drug problems (M = 44.99). As a result of these findings, the remaining analyses were collapsed across counselor and presenting problem for trustworthiness while the full five-factor design was retained for expertness and at- tractiveness. Because the trustworthiness results were central to the study, the coun- selor differences noted above did not detract from the main thrust of the study. Trustworthiness and Attractiveness An ANOVA of trustworthiness ratings re- vealed a significant main effect of confi- dentiality on trustworthiness, F(2, 153) = 10.87, p < .001. In addition, significant Problem Seriousness X Confidentiality In- teraction for trustworthiness, F(2, 153) = 4.70, p < .01, was obtained (Table 1). A close inspection of Table 1 reveals that the main effect of trustworthiness was a function of one deviant group; the high- problem-seriousness-nonconfidential con- dition. Therefore, the interaction was seen as the more appropriate level at which to interpret the findings. Essentially, when counselors decided to breach confidentiality with clients who had very serious presenting problems they were seen at least trustwor- thy. Although the attractiveness scale of the CRF was not central to the study, inspection of Table 1 reveals that the attractiveness ratings paralleled, to some extent, the trustworthiness ratings. However, the scores were less extreme and differences less pronounced. The breaching of confidenti- ality with serious client problems did not significantly diminish the counselor's at- tractiveness as it did with trustworthiness. However, maintaining confidentiality did enhance attractiveness with clients who were experiencing highly serious problems. As in previous studies, the correlations among the scales of the CRF were high. The correla- Table 1 Means and Standard Deviations for Trustworthiness and Attractiveness Scores as a Function of Confidentiality Condition and Level of Problem Seriousness Problem seriousness Experimental condition High Moderate M SD M SD Trustworthiness Confidential Nonconfidential Control 60.37 b 10.85 55.30 b 12.18 43.88" 14.97 52.09 b 11.59 54.35 b 13.26 54.58 b 11.03 Attractiveness Confidential 53.35 b 10.47 45.66" 14.01 Nonconfidential 42.38" 13.53 45.47" 12.86 Control 48.12" b 14.39 47.18" b 11.80 Note. A higher score indicates greater perceived trustworthiness or attractiveness. Different letters indicate that means were significantly different. Trustworthiness scores were different at p < .01, whereas those for attractiveness were different at p < .05. CONFIDENTIALITY AND TRUSTWORTHINESS 249 Table 2 Means and Standard Deviations for the Confidentiality Conditions on the Measures of Predicted Outcome, Endorsement for Referral and Counselors' Understanding of the Client's Problem Measure Outcome Referral Understanding Experimental condition M SD M SD M SD Confidentiality Nonconfidentiality Control 7.28 b 5.42 7,06 b 3,35 2.68 2.96 8.75 b 6.33" 9.07 b 5.70 4.10 5.03 8.96 b 6.53" 8.39 b 3.42 3.10 2.95 Note. A higher score indicates more chance of favorable outcome, greater likelihood of referring a friend or more feeling of being understood. Different letters indicate means significantly different at p < .05. tion between the trustworthiness and ex- pertness scale was .74; trustworthiness and attractiveness, .76; expertness and attrac- tiveness, .72. Ancillary Measures Analyses (ANOVA) revealed significant main effects of confidentiality for the coun- selors' degree of understanding of the client, F(2,153) = 9.84, p < .001, expected outcome, F(2,153) = 7.23, p < .001, and endorsement for referral, F(2,153) = 5.73, p < .004. Post hoc analysis (Tukey HSD; Kirk, 1968) indi- cated that counselors in the nonconfidential condition were significantly lower than counselors in the confidential and control conditions across all three measures (Ta- ble 2). TableS Frequency of Yes and No Responses to the Question of Whether Confidentiality Should be Maintained Condition Non- Response Confidential confidential Control Highly serious problems Yes No 15 17 15 19 20 14 Moderately serious problems Yes No 19 17 14 18 18 24 Finally, analyses were performed on the following questions: (a) Do you think the counselor should tell someone about this (problem)yes or no? (b) If yes, whom do you think he should tellparents, police, colleague, supervisor, head of dorm, or friend? For the first question two two-way tables were constructed, one for highly seri- ous and one for moderately serious client problems. In each table the frequency of yes and no responses was crossed with the three confidentiality conditions. There were no significant effects in responses for highly serious problems, but there was a significant effect x 2 (2) = 6.00, p < .049, for moderately serious problems (Table 3). Subjects were more likely to endorse breaching confiden- tiality in the moderately serious client problems condition. For the second ques- tion (concerning to whom the information should be divulged), simple frequency counts were conducted because subjects had been inadvertently allowed to check more than one person. The results suggested that the most popular choices were another col- league and parents followed by a friend, a supervisor and head of the dorm, respec- tively. Also, for highly serious and moder- ately serious problems parents were chosen equally. However, in choosing colleague and supervisor, subjects discriminated between highly serious and moderately serious problems such that only for high serious problems would they more frequently en- dorse disclosure to a colleague or supervisor. Finally, police was not chosen as a possible source by any subject. 250 THOMAS V. MERLUZZI AND CHERYL S. BRISCHETTO Discussion The Confidentiality X Problem Serious- ness interaction on trustworthiness indicated that counselors who breached confidentiality in cases involving highly serious problems were perceived as less trustworthy. Ap- parently, subjects believed that confidenti- ality was important with problems of a very serious nature and less critical with moder- ately serious problems. Perhaps, in the highly serious situations with more drastic consequences, subjects' ratings reflected how the breach in confidentiality might erode the counselor's trustworthiness. With moder- ately serious problems, on the other hand, subjects did not foresee any serious conse- quence if the information was released. In that condition it made little difference whether the counselor divulged information or maintained confidentiality: the coun- selor's trustworthiness was not compro- mised. Although no norms are available for the CRF scales, the mean trustworthiness score obtained by counselors in the high- problem-seriousness-nonconfidential con- dition was very low compared to scores ob- tained in other studies the authors have conducted. Additionally, subjects were more likely to refer friends, to feel the client was better understood, to suggest a more favorable outcome and see the counselor as more attractive in instances in which coun- selors maintained confidentiality. Finally, the comparable trustworthiness scores in the Confidential and Control conditions suggest that in the absence of a confidentiality ma- nipulation subjects assumed that confiden- tiality would be maintained. In addition to the major findings reported above, information was gathered on ques- tions that might suggest how subjects felt about the problem of confidentiality. With highly serious problems subjects registered an equal frequency of yes and no responses concerning whether the information should be divulged. However, inspection of Table 3 reveals that in the control condition more subjects favored maintaining confidentiality. With moderately serious problems the subjects were more likely to favor divulging the information. That effect was most prominent in the control conditions in which no cues concerning the counselor's intent were given. These findings reinforce the results obtained on trustworthiness ratings: With serious problems confidentiality is preferred. On the question concerning who would be the most appropriate referral source, the most popular choices were another colleague and parents, followed by a friend, supervisor, head of the dorm. Police was not chosen by any subjects as a potential referral source. For more personal sources like parents, subjects endorsed disclosure for highly se- rious and moderately serious problems with equal frequency. However, for more im- personal sources like a colleague or super- visor, they more frequently endorsed dis- closure only in cases of highly serious prob- lems. The results of this study are preliminary and, by the very nature of the problem, are based on analogue methodology. However preliminary the findings, the results suggest that even in circumstances in which coun- selors are reasonably emphatic and caring as well as deliberate in their decision to breach confidentiality, trustworthiness is compromised. In contrast to the extreme be- haviors used to enact untrustworthy be- havior in previous studies, the present study suggests that confidentiality alone may be a key ingredient in perceived trustworthiness. Moreover, the decrement in trustworthiness may occur primarily in situations in which the clients' concerns are of highly serious nature. The results should not lead to the conclusion that we should abandon breach- ing confidentiality under any circumstances. Rather it suggests that the decision to do so is associated with specific consequences that may affect the counselor's ability to be in- fluential with the client. It is interesting to note that degree of ex- perience did not affect perceptions of trustworthinessnor was there any inter- action of experience with any other inde- pendent variables. One might have antici- pated that highly experienced counselors may not have been seen as less trustworthy in situations in which confidentiality was breached. Possible explanations of the ob- tained findings are that (a) the experience- level manipulations were weak, (b) the quality of the counselors' responses in the dialogue may have dispelled the notion that CONFIDENTIALITY AND TRUSTWORTHINESS 251 the nonexperts were also incompetent, or (c) the confidentiality manipulations "masked" or neutralized the experience-level differ- ences. As noted above, a limiting factor in this study is the fact that it was conducted via audiotaped, contrived counselor-client in- teractions. Although one would not conduct this research with actual clients for obvious ethical reasons, it may be conceivable to approximate more closely the counseling situation. It is our opinion that face-to-face interaction and the counseling relationship might modify, somewhat, the impact of breaching confidentiality. Perhaps the quality of the relationship could be manip- ulated in an analogue setting by varying the level of empathy, respect, and genuineness displayed by the counselor. The reality of the situation might be enhanced by having the subjects role-play a client after an elab- orate role induction. The major hypothesis might be that the quality of the relationship may be determinant of the subject's (client's) perception of the counselor who breaches confidentiality. N Thus, loss of trustworthi- ness may be attenuated in the context of a high quality therapeutic relationship. Conclusion A recent court case, Tarasoff v. Regents of the University of California (1974) prompted us to look more closely at the area of confidentiality and its relationship to perceived trustworthiness. That case has been the impetus for many recent publica- tions in law, psychology, and psychiatry that examine and debate the importance of con- fidentiality in counseling (Stone, 1976). There are those who argue that counselor- client privilege must be preserved at all costs lest the counseling relationship be destroyed and the counseling process rendered useless. Others are convinced that confidentiality should be violated when certain conditions prevail. Although it is beyond the scope of this study to resolve the issues involved in the Tarasoff decision, it does suggest that confidentiality may directly affect perceived trustworthiness. Perhaps as research de- velops in this area we may begin to accu- mulate evidence that may be valuable to those involved in the legal decision making process. References American Psychological Association. Ethical princi- ples of psychologists. American Psychologist, 1981, 36,633-638. Barak, A., & LaCrosse, M, B. Multidimensional per- ception of counselor behavior. Journal of Counsel- ing Psychology, 1975,22, 471-476. Corrigan, J. D., Dell, D. M., Lewis, K. N., & Schmidt, L. D. Counseling as a social influence process: A re- view. Journal of Counseling Psychology, 1980,27, 395-441. Heppner, P. P., & Dixon, D. N. A review of the inter- personal influences process in counseling. Personnel and Guidance Journal, 1981,542-550, Kirk* R. Experimental design: Procedures for the behavioral sciences. Belmont, Calif,: Brooks/Cole, 1968, LaCrosse, M. B., & Barak, A. Differential perception of counselor behavior. Journal of Counseling Psy- chology, 1976,23,170-172. LaFromboise, T. D., & Dixon, D. N. American Indian perception of trustworthiness in a counseling inter- view. Journal of Counseling Psychology, 1981,28, 135-139. Rothmeier, K., & Dixon, D. N. Trustworthiness and influence in a counseling interview. Journal.of Counseling Psychology, 1980,27,315-319. Stone, A. The Tarasoff decisions: Suing psycho- therapists to safeguard society. Harvard Law Re- view, 1976,90, 358-378. Strong, S. R. Counseling: An interpersonal influence process. Journal of Counseling Psychology, 1968, 15, 215-224. Tarasoff v. the Regents of the University of California et al, Sup. 118 (California Rep. 1974,129-145). Received April 29,1982 Revision received November 5,1982
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