Description of the Working Model and Clinical Examples
The research I carried out on this topic was based on interviews I conducted with ten arts therapists who have between 3 and 22 years of field experience. The arts therapists attended accredited universities or colleges in Israel and work in schools in different areas of the country. The objective was to examine arts therapists’ perceptions on the issue of maintaining therapeutic confidentiality within the school setting. This work was prompted by an acknowledgment of the complexity of maintaining confidentiality in systemic work in schools, despite the importance of teamwork and the importance of sharing information about students. It was conducted to expand the theoretical scope on this subject, to better understand and analyze the complexities involved and to find solutions to improve the current situation.
When Should Information Emerging in Arts Therapy Be Made Available to Third Parties? The Need for a Gradual Process
According to the ethical codes of the therapeutic and medical professions, the therapist is obligated to report to the authorities when a client exhibits a genuine intention to commit a crime or cause harm to him/herself, to others or to property. This is also the case when the therapist suspects child abuse or neglect or when a court issues a warrant for such information (Carmichael, 2006; Moon, 2006). However, the way this rule is applied varies considerably such that in some cases it is unclear whether the duty of reporting applies to therapists.
Often I have found myself and my fellow school arts therapists colleagues debating the issues as to when we should share information disclosed in therapy to third parties, who should have access to this information and the appropriate method to convey it. In many cases when I felt the need to share information or the obligation to report information, I felt that for the benefit of the client and the therapeutic process, time was needed for consultation, deliberation or clarification with the client to have a clearer picture and choose the appropriate course of action.
In my research, one of the arts therapists described the dilemmas related to a student at risk with whom she worked. Some of the content that the student disclosed to her was conveyed outside the therapy room. It was not entirely clear to her whether this was a criminal case which she would be required to report. She decided to wait to report until she talked further with the client and consult with a psychologist and a colleague. After doing so, she realized that she was not obligated to report the issue. Thus, the postponement of reporting to external parties seems to be crucial in some cases.
Another similar case occurred when I was treating a child who was living with a foster family. The child’s parents were divorced, and his mother was dealing with mental illness. The child told me that during his visits to his mother, men came to see her, touched her and took items from her room and that he felt unsafe. When he shared this with me, he asked me not to disclose this information outside of the therapy room because he feared that it would endanger his younger brother who has a severe syndrome and lives with his mother, and might be placed in foster care as well. From the beginning of the therapeutic process, we discussed the subject of confidentiality and because it was important for me to continue to allow him to feel a sense of security and trust in me, I tried to understand what the right thing would be to do before reporting the incident to minimize the expected consequences of disclosure. As a result, I consulted with the social worker as well as his school counselor and teacher in an attempt to make an appropriate decision for the student and manage the information disclosure process accordingly. The time I invested in consultation actually helped me as an arts therapist to feel safer and more accepting of the process that occurred at a later stage. It enabled me to share my concerns with the client about the exposure and my considerations which arose from the need to protect him in the precarious situation he was exposed to. It is worth noting that despite the gradual process of transmitting information from therapy to external parties, the client had feelings of intrusiveness and said that he was not yet ready for external intervention. He felt hurt and disappointed that I had disclosed information that he brought up in therapy. After disclosing the information, despite my attempts to act in the best interests of the client during the therapeutic process and when transmitting the information, I was still slightly disappointed with the outcome of the situation, since the client felt disappointed and uncertain, and it felt as though the therapeutic process had spiraled out of control. After the disclosure of information and the crisis that ensued, we had to process the complex events it entailed and its implications for our relationship. With all the complexities in this situation, the client continued to attend arts therapy, and we emerged from the crisis together. This case taught me that building trust within relationships, stating the limitations of confidentiality at the beginning of the therapeutic process, along with the gradual and slow process of disclosing information from therapy, allowed for the continuation of therapy following the crisis.
These cases emphasize the need for the arts therapist to reach understandings and arrive at decisions as to the best way to deal with the client at the various stages of disclosure. In my experience, there are situations where it is not possible to consciously manage this process in advance due to the complexity of the processes and the level of urgency of disclosure. However, in situations where this is possible and significant emotional content related to reporting can be processed, it is important for the arts therapist to be active in presenting the therapeutic information on these issues concerning confidentiality and during the stages of disclosure.
When the arts therapist understands clearly that the information disclosed in therapy needs to be reported, there is time to prepare the client before the reporting process. It is beneficial to explain the reasons why the therapist has decided to report information to the client. The therapist can describe his/her perceptions and feelings about the physical and/or mental dangers threatening the client, or those close to the client. The professional decision to disclose the information is made by the therapist; however, if the therapist shares his/her motivations with the client, as well as thoughts and feelings that led to this decision, this process may allow the client to feel part of the decision and somewhat in control of the situation and its unfolding. The preparation process is important because it may allow for processing of the client’s fears of exposure and prepare him/her for future scenarios. Acknowledging and validating the content that will be reported, as well as allowing for the processing and containment of such content, are of immense importance.
During the exposure stage, it is important for the arts therapist to accompany the client in the processes that he/she is experiencing. Conscious and unconscious internal processes should be addressed when the client is confronted with the disclosure and clients should be made aware of the meaning and implications of these mental processes. This accompaniment stage enables the client to have curative experiences when dealing with feelings such as harm, danger, lack of control, helplessness and other feelings, which the client or someone close to the client may have experienced in the deleterious conditions that led to the reporting of information.
Once the information is disclosed, all the components of the process that took place must be processed. It is important to allow the client to examine how he/she perceived the experience of disclosure and its meaning, and to elaborate on the way the client thinks about and experiences it. The purpose is to allow the client to view the experience from an integrative perspective that can contain the aspects that he/she may perceive as adverse to the process of disclosure, and also those that embody the protection and support needed as a result of the disclosure. The very existence of the arts therapist and client’s shared dialogue during these processes can strengthen the relationship, the therapeutic alliance and the level of trust.