5.2 Client Rights
Client’s Autonomy to Access Records and Treatment
A foundational principle in counseling is that clients have autonomy to make informed decisions about their care. Counselors, within reasonable means, must provide clients with the proper care and treatment coordination. Clients have the right to be treated with respect and have the right to refuse treatment. Sometimes, a client’s autonomy in treatment may pose an ethical dilemma, especially when the client’s requests may go against the counselor’s responsibility to be honest about the client’s condition.
Case Example: Regina
A client has been seeing Regina for therapy sessions. The client requested access to a diagnostic assessment conducted by Regina so the client could apply for social security services. However, upon receiving the documentation, the client disagreed with Regina’s diagnosis as it was not what the client wanted, and it would not get her the social security benefits she needed. Regina shared with the client that the client’s reported symptoms do not align with the diagnosis that the client assumed they had. Hence, Regina concluded with the diagnosis that best fits the client’s mental health presentation. The client was furious and refused to continue services with Regina.
Discussion of Case Example
One of the significant issues with this case is the client’s desire to be diagnosed with a disorder that Regina did not believe the client had. However, providing the client with a diagnosis they did not have would go against the ethical principle of veracity, providing honest communication about a client’s condition, even when it would lead to the client being denied social security benefits. On the other hand, there is the dilemma of the client not having access to social security benefits, which is the only source of income for the client. In this case, the counselor’s responsibility to practice veracity precedes the client’s request to get a diagnosis that qualifies them for social security. In this case, the client had the right to refuse services and seek another diagnostic assessment or further explanation by the agency supervisor on the concluded diagnosis. The ACA (2014) discusses this practice in its ethical code:
“When clients request access to their records, counselors provide assistance and consultation in interpreting counseling records” (Standard B.6.f.).
There will be instances when certain records or notes may need to be concealed from the client as it may cause harm to the client. In such cases, a counselor, after consultation with supervisors and co-workers, can take reasonable steps to withhold information. However, they must provide the client with the rationale for withholding such information. The ACA (2014) provides guidance for this type of situation as well:
Counselors provide reasonable access to records and copies of records when requested by competent clients. Counselors limit clients’ access to or portions of their records only when there is compelling evidence that such access would cause harm to the client. Counselors document the requests of clients and the rationale for withholding some or all of the clients’ records in their files. In situations involving multiple clients, counselors provide individual clients with only those parts of records that relate directly to them and do not include confidential information related to any other client (Standard B.6.e.).
Case Example: Samantha
Discussion of Case Example
This case highlights the balance between client autonomy and well-being. Samantha must navigate transparency versus potential harm, as granting full access to Claire’s notes risks retraumatization or misinterpretation. By reviewing the notes together, Samantha ensures Claire’s safety while respecting her autonomy, aligning with ethical principles of beneficence and nonmaleficence.
Collaborative review fosters trust and allows Samantha to clarify clinical language, preventing misunderstandings that could harm the therapeutic alliance. The case also underscores the importance of clear record release policies and informed consent, ensuring ethical management of sensitive information. This example invites reflection on balancing ethical obligations, maintaining client trust, and seeking supervision for complex dilemmas.
Case Example: Release of Information
On their first day in treatment, a client was asked to sign a release of information (ROI) for treatment coordination, which included a social work team, a pharmacy, a nearby emergency hospital, and her probation officer. The client expressed intense fear of being incarcerated to her primary counselor, Linda, who attempted to provide interventions to address the client’s fears. The client, however, disclosed she returned to using recently and asked to revoke the ROI to the probation officer. The client feared her urine drug screen results would be sent to her probation officer, and the client would be arrested for probation violation. Linda encouraged the client to discuss the results with the probation officer. However, the client refused and insisted on revoking the release of information to the probation officer. After the client revoked the release of information, any calls from the client’s probation officer to ask for an update about the client’s treatment could not be followed up due to the release of information being revoked. The supervisors decided the client would be discharged as she was not following the probation requirements, and it would be difficult for the treatment center to maintain confidentiality.
Discussion of Case Example
This case highlights the ethical conflict counselors may face when a client exercises their autonomy by revoking a release of information. In this scenario, the counselor is unable to provide updates to the client’s probation officer, as required by the terms of their probation. While in some situations, the primary counselor might collaborate with the probation officer to keep the client in treatment, the client’s history suggests that revoking the release could result in a warrant being issued for their arrest, obligating the client to face legal consequences. This situation creates a dual risk: potential legal repercussions for the client and a breach of confidentiality if the counselor were to disclose information without proper authorization. Addressing this issue requires peer consultation and a thorough analysis of all available options to ensure ethical and client-centered decision-making.
The ACA (2014) discusses this practice in its Code of Ethics:
“Unless exceptions to confidentiality exist, counselors obtain written permission from clients to disclose or transfer records to legitimate third parties. Steps are taken to ensure that receivers of counseling records are sensitive to their confidential nature” (Standard B.6.g.).
NAADAC (2021) offers similar guidelines:
“Unless exceptions to confidentiality exist, addiction professionals shall obtain written permission from clients to disclose or transfer records to legitimate third parties. Providers shall ensure that receivers of counseling records shall be made aware of their confidential nature. Addiction professionals shall ensure that all information released shall meet requirements of 42 CFR Part 2 and HIPAA. All information released shall be appropriately marked as confidential” (Standard II-22).
Key Takeaways
- Counselors are legally required to report suspected abuse or harm, balancing their responsibility to protect clients with maintaining trust and transparency in the therapeutic relationship.
- Clear communication about confidentiality, its limits, and the counselor’s responsibilities ensures clients are empowered and aware from the outset of the counseling relationship.
- Proper use of ROIs respects client autonomy while facilitating collaboration and continuity of care, requiring clear documentation and ethical decision-making.
- Counselors must respect client autonomy while recognizing situations where legal or ethical obligations may require intervention.
- Maintaining thorough and accurate documentation supports ethical practices, protects client rights, and reduces the risk of liability or malpractice claims.