Mental health articles

College clinicians uphold confi dentiality because students won’t speak openly
or even visit the service otherwise. Confi dentiality and privacy are central tenets of
mental health professionals’ codes of ethics, mental health services’ accreditation
standards, and legislative acts, i.e., the Family Educational Rights and Privacy
Act (FERPA) and the Health Insurance Portability and Accountability Act
(HIPAA). Th ere are exceptions to confi dentiality, of course, which, depending
on state laws, generally have to do with imminent or signifi cant danger to self or others, court-ordered subpoenas, and suspected child abuse. But the
essence of confi dentiality policies, the way they’re explained in informed consent
agreements, is that these are truly exceptions. What’s said at the counseling
center, even the fact of going there, isn’t shared with outsiders.
Th at being said, confi dentiality, like administrative neutrality, has always
been something of an uphill fi ght for college mental health services. Campuses
are small and interconnected communities whose members fi nd it natural
to pump clinicians for information. Oft en the questioner starts with the disclaimer
“I don’t want to know anything confi dential” and then proceeds to ask
for just that: “Just tell me if he came in,” “Just tell me if she’s okay,” or “I just
got this distressing e-mail from her. What do you make of it?” Th e request for
information may come from the professor or academic advisor who referred
the student for counseling. Or a residence hall director, vice president, or dean
may call, who can claim information on a need-to-know basis and may be in
a position to help the student—and certainly won’t appreciate hearing a priggish
or withholding answer from a colleague or subordinate. (Again, college
mental health services ignore campus opinion at their peril.) Parents call too,
of course, and while their input can be famously intrusive and off -the-wall,
more oft en than not they are rightly concerned about their child. Finding a
diplomatic and helpful response to these various questioners without inappropriately
divulging confi dential information has been a perennial struggle
for college practitioners. And deciding when to take the initiative in revealing
information or when safety or community concerns should override confi –
dentiality is equally confounding.
A trio of legal developments has put further pressure on upholding confi –
dentiality practices. Th e fi rst, the Tarasoff case of 1976, made clinicians more
likely to warn potential victims about patients’ violent intentions (VandeCreek &
Knaff , 2001). Th en in 1987, the drinking age was raised to 21, aft er which privacy
laws were amended so that colleges could notify parents about drinking
violations by underage students (Sontag, 2002). Now comes the Elizabeth
Shin shocker, fi nally settled aft er a period of great uncertainty (Hoover,
2006), in which the parents of an MIT student who immolated herself sued
the university for negligence. Particularly as a result of “Elizabeth Shin”—like
Tarasoff , her name has entered the student aff airs idiom—colleges are likelier
now to notify parents and other campus personnel about risky students, even
(if deemed necessary) without the students’ permission. And while administrators
and clinicians have diff erent thresholds and criteria for divulging
information, plainly the bar has lowered for everyone, clinicians defi nitely
included. Fift y-fi ve percent of counseling-center directors now report that it is
legally permissible to notify parents if a family-dependent student is hospitalized—
a whopping 22% increase over the prior year’s survey (Gallagher, 2004).
Th e oft -repeated rationale for disclosing privileged information about
a student is convincing: Better a lawsuit for violating confi dentiality than dent
than respect his or her autonomy. But as with forced hospitalizations
and forced medical leaves, this reasoning assumes that disclosing information
makes students safer. Once again, that’s not always true. Some parents
play a toxic role when told about a crisis. And while some students may feel
protected when clinicians breach confi dentiality, other students lose trust in
treatment, and so are at greater risk.
Th e problem goes even deeper than that. Once exceptions to confi dentiality
become established practice, they stop being exceptional. Pretty soon,
more people on- and off -campus insist on their need to know confi dential
information. More occasions seem to demand it—the defi nition of imminent
or signifi cant danger is widened. Such chipping away at the foundation of confi
dentiality undermines the mental health service’s credibility and ultimately
its ability to reach students, as Hanfmann (1978) powerfully argued nearly
three decades ago.
In the end, there are no absolute answers. Legal and ethical obligations
and clinical reasons line up in support of confi dentiality. Th ey may also, along
with community concerns and political circumstances, justify breaking it.
In confi dentiality matters as with other aspects of college mental health, the
judgments only grow tougher.