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ORIGINAL ARTICLE

Adolescents, Risk Behaviour and Confidentiality: When Would

Australian Psychologists Breach Confidentiality to Disclose
Information to Parents?
Rony E Duncan,1,2,3,4 Ben J Williams,4 and Ann Knowles4
1
The Centre for Adolescent Health, Royal Children’s Hospital, 2Murdoch Childrens Research Institute, 3Department of Paediatrics, The University of
Melbourne, and 4Psychological Sciences and Statistics, Faculty of Life and Social Sciences, Swinburne University of Technology

The protection of confidentiality in psychological practice is vital. However, confidentiality is not absolute and psychologists are permitted to
breach confidentiality under particular circumstances. Ethical challenges surrounding confidentiality are complex with adolescent clients, as
assessments often consider the risk that adolescents pose to themselves in addition to the risk posed to others. The current study documented
situations in which Australian psychologists would breach adolescents’ confidentiality to disclose information about risk behaviour to parents,
with a focus on situations where adolescents posed a risk to themselves as opposed to other people putting adolescents at risk. A total of 264
Australian psychologists were surveyed online. They were each presented with 68 variations of a vignette about a 15-year-old boy who was
engaged in risk behaviour and were asked whether they would breach confidentiality in each case. The vignettes covered six behavioural
domains (smoking, sexual behaviour, drinking, drug use, suicide, stealing) and varied in behaviour intensity, frequency and duration. Consensus
was reached about breaching confidentiality in 16% of cases (related to sexual behaviour, drug use, and suicide). Consensus was reached about
not breaching confidentiality in 41% of cases (relating to smoking, sexual behaviour, drug use, suicide, and stealing). In the remaining 43% of
cases, significant disagreement occurred (relating to all six behavioural domains). The findings suggest a high degree of variation in opinion about
confidentiality with adolescents, emphasising the importance of transparent communication and informed consent. The findings also raise
questions about how important consistency of psychological practice is across Australia.

Key words: adolescent; confidentiality; ethics; minors; psychiatry; psychology.

What is already known on this topic What this paper adds

1 Confidentiality is necessary if adolescents are to disclose sensi-
tive and personal information to health professionals.
2 Confidentiality in the psychological setting is not absolute. Psy-
chologists are permitted to breach confidentiality under a range
of circumstances, including when an immediate and specified
risk of harm is present.
3 Adolescent clients pose specific challenges regarding confiden-
tiality for psychologists because assessments of risk need to
include not only the level of risk they pose to others but also the
level of risk they pose to themselves.
1 The current article presents the views of 264 Australian psycholo-
gists about whether they would breach confidentiality with an ado-
lescent client to disclose information about risk behaviour to
parents across 68 different vignettes. This is an important resource
for professionals to contrast their own views and current practice.
2 Respondents reached consensus about whether to breach confi-
dentiality in the most high-risk and low-risk vignettes that were
presented. However, in 43% of cases, respondents failed to reach
consensus about whether a breach of confidentiality was neces-
sary. This implies considerable variation among Australian psy-
chologists’ views regarding confidentiality with adolescent clients.
3 Given that variation exists in psychologists’ opinions about con-
fidentiality with adolescent clients, it is likely that current practice
varies also. It is therefore imperative that psychologists are clear
in their communication with adolescent clients and clients’
parents about their limits to confidentiality in order to uphold
principles of transparency and informed consent.

Correspondence: Rony Duncan, Centre for Adolescent Health, Level 2, Royal Children’s Hospital, Parkville, VIC 3052, Australia. Fax: +61 (3) 9345 6273; email:
rony.duncan@mcri.edu.au
Accepted for publication 23 October 2012
doi:10.1111/ap.12002

408 Australian Psychologist 48 (2013) 408–419

© 2012 The Australian Psychological Society

RE Duncan et al.
Confidentiality is essential for building effective therapeutic
relationships within the psychological practice. However, psy-
chologists have also described confidentiality as the cause of
their most serious ethical dilemmas (Haas, Malouf, & Mayerson,
1986; Pope & Vetter, 1992). Although fundamental, confiden-
tiality between therapists and clients can never be absolute, and
it is this stipulation that creates scope for ethical complexity and
confusion (Jain & Roberts, 2009; Kampf, McSherry, Thomas, &
Abrahams, 2008). Determining appropriate limits to confiden-
tiality, and making decisions about which cases require a breach
of confidentiality, can be highly challenging and ethically
fraught. This is especially true when clients are minors.
The phase of adolescence is often defined by societies in
relation to a combination of age and social roles, which can
result in little consistency across countries (Sawyer et al., 2012).
Unless otherwise stated, in the current article we use the terms
“adolescents,” “young people,” and “minors” interchangeably
to refer to people under the age of 18 years, in line with the
Australian Psychological Society (APS) definition of “young
people” (Australian Psychological Society, 2009). However, we
note that international definitions of adolescence are moving
towards a broader definition, encompassing those aged 10–24
years (Sawyer et al., 2012). This broader age-range is reflected
in some of the literature we reference.
Guidelines Concerning Confidentiality
Current guidance regarding confidentiality within psychological
practice is internationally consistent. The APS has published
the Code of Ethics (Australian Psychological Society, 2007). This
requires psychologists to “safeguard the confidentiality of infor-
mation obtained during their provision of psychological serv-
ices” (p, 15). The Code also clarifies circumstances under which
psychologists are permitted to disclose confidential information
that has been provided to them by their clients. These include
situations in which the client (or the client’s legal guardian)
has provided consent, where there is a legal obligation to do so,
where there is an immediate risk of harm that can only be
averted by disclosing information, or when colleagues or super-
visors need to be consulted.
The APS has also recently published a detailed set of guidelines
specifically on working with young people (Australian Psycho-
logical Society, 2009). In relation to confidentiality, these guide-
lines are definitive about the need to prioritise young people’s
best interests above those of parents, as long as young people are
deemed competent. The guidelines specifically state that “psy-
chologists respect the young person’s wishes regarding confiden-
tiality and do not divulge any confidential information contrary
to the young person’s wishes, except as specified in section
5.1—Limits to Confidentiality” (p, 183). The “limits to confiden-
tiality” referred to are in line with those outlined in the APS Code
of Ethics, described above.
The American Psychological Association (APA) also has a Code
of Conduct (American Psychological Association, 2002). This
closely mirrors the guidance outlined in the APS Code of Ethics,
although a specific discussion of therapy with young people is not
present. In addition to the APA’s Code of Conduct, the American
School Counselor Association (ASCA) has published a document
titled “Ethical Standards,” and this outlines the obligations
Australian Psychologist 48 (2013) 408–419
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Adolescents, risk behaviour and confidentiality
regarding confidentiality with students specifically (American
School Counselor Association, 2004). School psychologists
working in the USA are advised that their primary obligation is to
the student and that information should remain confidential
unless disclosure is required to prevent clear and imminent
danger to the student or others, or when legal requirements exist.
Detailed guidance about confidentiality with adolescents also
exists outside the field of psychology. The position statements
of every major medical organisation, including the World Health
Organisation (WHO), support confidential health care for ado-
lescents (American Academy of Paediatrics, 2008; American
Medical Association, 1993, 1994; Berlan & Bravender, 2009;
Ford, English, & Sigman, 2004; Society for Adolescent Medi-
cine, 2004a; Wheeler, 2006; World Health Organisation [WHO],
2002). In particular, the Society for Adolescent Medicine (SAM)
has published a policy statement on confidential health care
for adolescents (Society for Adolescent Medicine, 2004b). This
states that “confidentiality is an essential component of health
care for adolescents because it is consistent with their develop-
ment of maturity and autonomy” (p. 160).
The Ethical Complexity
Surrounding Confidentiality
Despite the level of international consistency regarding
guidance about confidentiality in psychological practice, it has
been argued that the application of these seemingly simple
recommendations is in fact highly complex (Davis & Mickelson,
1994; Gustafson & McNamara, 1987; Isaacs & Stone, 1999;
Kaczmarek, 2000; Ledyard, 1998; Myers, 1982; Taylor &
Adelman, 1989) and not well understood by practitioners
(Fisher, 2008; Haas et al., 1986; Pope & Vetter, 1992; Younggren
& Harris, 2008). Davidson (1995) in his review of articles con-
cerning confidentiality in psychological practice, explained that
disagreement exists in the field of psychology about what con-
stitutes harm and who should be protected. He also noted that
legal, ethical, and professional codes can compete with one
another which means that deciding which to follow can consti-
tute a challenging task. McMahon and Knowles (1995) argue
that although obligations of confidentiality are well known,
they are complicated by a range of factors such as legal protec-
tions, ethical beliefs, institutional practices, and professional
codes. The complexities associated with obligations of confiden-
tiality are therefore numerous, and it is perhaps not surprising
that previous research indicates psychologists are confused
about when to breach confidentiality (Kampf et al., 2008).
Adolescents, Confidentiality, and
Psychological Care
Much has been written about the way in which confidentiality
dilemmas are magnified when clients are minors (Sobocinski,
1990). Lawrence and Kurpius (2000) state that confidentiality
is one of the most difficult legal and ethical dilemmas facing
psychologists who work with minors. Milne (1995) argues that
issues regarding counsellor–client confidentiality pose particular
difficulties when counselling is provided to adolescents directly.
Isaacs and Stone (1999) suggest that managing confidentiality is
often the most difficult ethical issue facing school counsellors.
409

Adolescents, risk behaviour and confidentiality
McCurdy and Murray (2003) highlight the dilemmas that arise
during family therapy, when minors are often seen alone for
some sessions and may reveal private information during this
time that is pertinent to the family situation. Several authors
have also noted the ambiguity of professional codes and laws
regarding confidentiality with adolescent clients specifically
(Isaacs & Stone, 1999; Lawrence & Kurpius, 2000; McCurdy &
Murray, 2003; Mitchell, Disque, & Robertson, 2002; Moyer &
Sullivan, 2008; Sealander, Schwiebert, Oren, & Weekley, 1999).
Less well articulated in existing literature is why young people
pose such a problem for notions of confidentiality in the psy-
chological setting. That is, what makes adolescents so different
from adults and thus the cause of such additional ethical uncer-
tainty? Adolescents differ from adults in their cognitive, psycho-
logical, and social capabilities and also in relation to the extent
of life experience they have had (Hazen, Schlozman, & Beresin,
2008). When contemplating ethical challenges of confidentiality
with adult clients, dilemmas often relate to whether the client
poses a risk to others; sometimes referred to as determina-
tions of the “dangerous” client (McMahon & Knowles, 1997).
However, with adolescents, determinations about confidential-
ity often relate to whether the young person poses a risk to
themselves as a consequence of engaging in risk behaviours. Such
determinations necessarily entail an assessment of maturity or
competence as well, further increasing the ethical complexity.
Psychological care is vital for adolescents, with research indi-
cating a range of reasons to be concerned about their health and
well-being. Worldwide, there are over 1.8 billion young people
aged 10–24 years, which is the largest adolescent population in
history (Sawyer et al., 2012). Alcohol misuse alone is estimated
to account for 31.5% of all the deaths in 15–29 year old men in
the developed world (Toumbourou et al., 2007). Statistics from
the Australian Institute of Health and Welfare (AIHW) indicate
that almost one third of Australian young people aged 12–24
years of age drink alcohol in amounts that put them at risk of
harm in the short term, and around 17% are current smokers
(Australian Institute of Health and Welfare, 2007). In relation to
sexual practices, 26% of Australian youth aged 12–24 years have
engaged in sexual intercourse by the time they reach Year 10,
rising to 47% by Year 12. Disturbingly, 25% of males and 20% of
females in Year 12 did not use a condom the last time they had sex
(Australian Institute of Health and Welfare, 2007). Injury con-
tinues to be the leading cause of death in those aged 12–24 years,
accounting for two thirds of all the deaths in this group.
The prevalence of mental health problems among Australian
adolescents aged 13–17 years is 19%, and this increases to
27% among young adults aged 18–24 years (McGorry, Purcell,
Hickie, & Jorm, 2007). In fact, mental health disorders account
for almost 50% of the total disease burden among young people
aged 12–24 years (Australian Institute of Health and Welfare,
2007). Prevention and early intervention are thus both possible
and highly desirable for adolescents (Sanci, Sawyer, Kang,
Haller, & Patton, 2005).
Empirical Research about Confidentiality in
Psychological Practice
Research with young people demonstrates that adolescents
place a high value on confidentiality. A survey of Melbourne
410
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RE Duncan et al.
high school students found that 98% of adolescents believed
that confidentiality within a school counselling setting was
either essential or important (Collins & Knowles, 1995). It has
also been shown that the number of disclosures regarding sen-
sitive questions is higher when confidentiality is explicitly
assured by psychologists (Kobocow, McGuire, & Blau, 1983).
Findings about the importance of confidentiality for young
people have also been demonstrated extensively in the field of
adolescent medicine (Farrant & Watson, 2004; Ford, Millstein,
Halpern-Felsher, & Irwin, 1997; Jones, Purcell, Singh, & Finer,
2005; Reddy, Fleming, & Swain, 2002; Thrall et al., 2000).
Most of the empirical research conducted with psychologists
and counsellors about confidentiality with adolescent clients has
come from the USA. Beeman and Scott (1991) surveyed Ameri-
can psychologists in training and asked them to rate the impor-
tance of a range of information provision to clients, finding that
information regarding the limits to confidentiality scored the
highest of all types of information proposed. Davis and Mickel-
son (1994) surveyed American school counsellors. They found
that there was less than 50% agreement on the preferred ethical
or correct legal choices in relation to dilemmas of student
privacy, confidentiality, and parental rights. Isaacs and Stone
have conducted two studies with American counsellors about
confidentiality with minors (1999, 2001). In the first survey
they asked school counsellors about the circumstances in
which they would breach confidentiality with clients who were
minors. The majority of counsellors reported that they would
breach confidentiality for the following issues: impending
suicide, retaliation for victimisation, use of crack cocaine, sex
with multiple partners when HIV positive, armed robbery, indi-
cations of depression, abortion, and marijuana use. They also
found that the degree of dangerousness and also the minor’s age
influenced counsellors’ decisions about breaching confidential-
ity (Isaacs & Stone, 1999). In their second study, they surveyed
mental health counsellors and found that the same two factors;
dangerousness of the behaviour and the client’s age impacted
on counsellors’ decisions about breaching confidentiality (Isaacs
& Stone, 2001).
Rae, Sullivan, and colleagues have conducted a number of
studies aimed at documenting when psychologists and counsel-
lors would breach confidentiality with adolescent clients and
what factors influence their decisions. The current study par-
tially replicated their initial study, which entailed a survey
74 American paediatric psychologists (Rae, Sullivan, Razo,
George, & Ramirez, 2002; Sullivan, Ramirez, Rae, Razo, &
George, 2002). Findings from this initial study were published
in two separate manuscripts. The first manuscript presented
the considerations that psychologists take into account when
making decisions about breaching confidentiality with adoles-
cent clients (Sullivan et al., 2002). Participants were presented
with 13 considerations and were asked to rate the importance of
each for their decisions about confidentiality. Factor analysis of
these responses provided support for a two-factor model to fit
the data. These two factors were termed “Negative Nature of
the Behaviour” and “Maintaining the Therapeutic Process.” The
second manuscript presented the circumstances in which psy-
chologists believed it was ethical to breach confidentiality with
adolescent clients (Rae et al., 2002). Vignettes describing a range
of adolescent risk behaviours were presented to participants,
Australian Psychologist 48 (2013) 408–419
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RE Duncan et al. Adolescents, risk behaviour and confidentiality

and they were asked to rate how ethical it would be to breach Table 1 A Comparison of Demographic Characteristics between the
confidentiality and inform parents. The risk behaviours covered Study Sample and APS Members
six behavioural domains and across all of these, psychologists % of sampleb % APSa
were more likely to indicate that a breach of confidentiality was
ethical as the intensity, frequency, and duration of the behav- State of registration
iour increased. NSW 29 32
Rae, Sullivan, and colleagues have since replicated this survey VIC 29 33
with school psychologists and school counsellors. In surveying QLD 15 19
school counsellors they found, again, that as the intensity, dura- SA 6 6
tion, and dangerousness of the risk behaviour increased, so too TAS 5 2
did the propensity for school counsellors to deem a breach of WA 12 8
ACT 3 3
confidentiality ethical. They also found that although agree-
NT 1 1
ment occurred about the ethicality of breaching confidentiality
Age
in high-risk circumstances, such as a suicide attempt, disagree-
<30 23 14
ment occurred among respondents regarding less high-risk
30–39 35 26
behaviours (Moyer & Sullivan, 2008). They also found that
40–49 20 23
school psychologists used a vast range of complex considera- 50–59 16 22
tions in determining whether a breach of confidentiality was 60+ 6 15
ethical (Sullivan & Moyer, 2008). In surveying school psycholo- Gender
gists they found, yet again, that as the intensity, duration, and Male 13 21
dangerousness of the risk behaviour increased, so too did the Female 87 79
tendency for school psychologists to breach an adolescent’s con-
a
fidentiality (Rae, Sullivan, Razo, & De Alba, 2009). Demographic data from membership profile in APS (2011) Annual Report.
b
The current study aimed to replicate the initial American study Two participants did not supply the state they were practicing in.
described above (Rae et al., 2002; Sullivan et al., 2002) in order
to examine the considerations that Australian psychologists use
for making decisions about confidentiality with adolescents and 3% of the participants were still completing their qualifications.
also to document the circumstances in which Australian psy- The psychologists sampled worked in a range of settings, with
chologists believe it is appropriate to breach confidentiality with 26% working in schools, 22% in private practice, 11% in the
adolescents. The findings related to the considerations that psy- public sector, and small numbers working in a university, com-
chologists use in making such decisions have been published munity, or government settings. Eighty-two per cent of the par-
separately (Duncan, Williams, & Knowles, 2012). Here, findings ticipants were members of the APS. Currently, there is no
are presented in relation to the circumstances in which Austral- available demographic profile of Australian psychologists who
ian psychologists believe it is appropriate to breach confidential- work with young people. However, data are available for the
ity with adolescent clients. The focus was circumstances in which overall APS membership (Australian Psychological Society,
adolescents were posing a risk to themselves, as opposed to 2011). The age distribution in the current study sample was
situations in which another person was putting the adolescent at broadly comparable to the APS membership, although respond-
risk. The findings of the current study offer an empirical basis for ents under 30 and over 60 years of age were overrepresented in
comparison so that Australian psychologists can contrast their the sample, as were women. These differences may reflect the
own practice and opinions with that of their colleagues. characteristics of psychologists who work with adolescents or
may be due to the means used to collect data (i.e., familiarity
with the Internet). The geographic distribution of our partici-
Method pants closely matched the APS membership profile, with the
exception that Tasmania and Western Australia were signifi-
Participants cantly over-represented. Table 1 presents a comparison of
Participants were required to be working in Australia, have demographic characteristics between the study sample and APS
experience working with young people, and either studying members.
to become or qualified as a registered psychologist. While 282 Materials
people responded to the questionnaire, 18 either did not fit
these criteria or omitted over 10% of the questionnaire items An online questionnaire was used to survey the psychologists
and were consequently excluded from the sample, leaving a in this study and was adapted from the previous study being
total of 264 participants. The majority (87%) of the participants replicated (Rae et al., 2002; Sullivan et al., 2002). The question-
were female, and 13% were male, with an overall mean age of naire consisted of two parts; Part A related to the situations in
39 years (SD = 11) and most lived in the Australian states of which psychologists would deem it appropriate to breach con-
New South Wales or Victoria. They had a mean number of 9.5 fidentiality with adolescents, and Part B related to the consid-
years experience working with young people (SD = 7.8). A total erations they take into account when making such decisions.
of 42% had completed a 4-year degree plus 2 years of supervi- This article reports results from Part A of the questionnaire only.
sion, 49% had completed either a Doctorate of Psychology or a Results from Part B have been published separately (Duncan
Masters Degree, 7% had completed a PhD, and the remaining et al., 2012).

Australian Psychologist 48 (2013) 408–419 411

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Adolescents, risk behaviour and confidentiality RE Duncan et al.

Table 2 The 68 Scenarios Presented in the Questionnaire (17 Categories of Risk Behaviour Each Divided into Four Levels of Frequency/Duration)

Behavioural domain 17 categories of risk behaviour Four levels of frequency/duration

Smoking Smoking one cigarette

Smoking more than a pack of cigarettes
Drinking One drink
Binge drinking
Sexual behaviour Sex with a girlfriend once several months ago
Sex with multiple partners monthly for several months
Unprotected sex while HIV+ weekly for several months
Drug use Using marijuana nearly daily for the last year
Using amphetamines
Using hallucinogens
Using inhalants
Suicide Suicidal ideation (“I wish I was dead”)

Suicide gesture (taking pills) once over a year ago

Suicide attempt (trying to hang himself) once several months ago
Stealing Stealing clothing from a store once during last month
Stealing a car more than once during last month
Breaking into homes and stealing valuables

Part A of the questionnaire used hypothetical vignettes to
document situations in which psychologists would breach con-
fidentiality with adolescent clients and disclose information to
the adolescents’ parents about risk behaviour. Participants were
first presented with the following hypothetical scenario:
Chris is a 15-year-old male who was referred by his parents for
disrespectful, acting out, and oppositional behaviour that has become
much worse in the last few months. Chris is an only child of working
parents who describe themselves as middle class. His parents have
brought Chris to treatment, and he is not enthusiastic about the
therapy since he does not believe that he has a “problem.” Chris is
also very concerned about confidentiality, but his parents have agreed
that they will not ask you for details about the content of the therapy
sessions. You assure Chris that you will only break confidentiality
to his parents (or others) if he presents a danger to himself or to
others. During the sixth therapy session, Chris begins admitting to
risk-taking behaviours.
6-point Likert scale. The authors of the previous study suggested
this alteration in design for future studies so that participants
would be forced to make a definitive choice, and more infor-
mation could be gathered about where the tipping point lies for
breaching confidentiality in such situations. The past study also
used two versions of the vignette, one that described a female
client and one that described a male client. The current study
did not vary the gender of the client in the vignette. This was
due to limitations of the online questionnaire tool used
(it was not possible to randomly allocate two versions of the
vignette online; one with a male client and one with a female
client). The previous American study used hard copies of the
questionnaire, and so the researchers were able to send out
two different versions. The 17 risk behaviours covered six key
behavioural domains. These were: smoking; drinking; sexual
behaviour; drug taking; suicide; and stealing. Table 2 presents
the 17 risk behaviours alongside the four levels of frequency/
duration that were presented in the questionnaire.

Participants were then provided with 17 different categories Procedure

of risk behaviour that Chris had engaged in, and each of the 17
categories was then divided into four separate levels of
frequency/duration. Thus, in total, there were 68 different sce-
narios (17 categories, each divided into four levels of frequency/
duration). For example, the first of the 17 categories was “Chris
admits to smoking one cigarette,” and the four levels of frequency/
duration related to this category were: once several months ago;
monthly for several months; weekly for several months; and nearly
daily for the last year. These 68 scenarios were taken from the
study being replicated.
For each of the 68 scenarios, participants were asked to indi-
cate whether they would breach confidentiality and inform
Chris’s parents about the risk behaviour. They did so on a binary
scale (yes, no), which differed from the previous American
study where participants were asked to rate “how ethical” a
breach of confidentiality would be in each scenario using a
Following the receipt of University ethics approval, requests to
participate were distributed in two ways. First, the study was
advertised through a fortnightly APS email newsletter and a
notice on the APS website with a link to the study website.
Second, participants were invited via personal emails, which
included details about the survey and a link to the survey
website. This email distribution used the snowballing technique
in which the researchers emailed colleagues who were then
asked to forward the email to their colleagues and so on. This
methodology meant that a response rate for the current study
could not be calculated as it is not known how many people
received notification of the survey.
Participants completed the survey online and submitted their
responses anonymously by clicking on a button titled submit at
the end of the survey. An incentive was provided to potential

412 Australian Psychologist 48 (2013) 408–419

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RE Duncan et al. Adolescents, risk behaviour and confidentiality

participants in the form of a $100 book/CD voucher prize draw. 100

Participants who wanted to be considered for this prize were
asked to provide a name and telephone number at the end of
80
the questionnaire. These details were separated from the ques-
Binge drinking

% would breach
tionnaire responses to maintain anonymity.
One drink
60
Smoking a pack of cigarettes
Results Smoking one cigarette
40
A cut-off of 80% agreement was used to indicate consensus
among participants about their views on whether to breach
20
confidentiality or not, in response to each vignette. This is con-
sistent with Pope, Tabachnick, and Keith-Spiegel (1988) who
argued that 80% indicated “a clear majority”. Figures 1 and 2 0
present the percentage of participants who would breach
confidentiality with an adolescent client to inform parents of
100
risk behaviour across the four levels of frequency/duration, for
each of the six behavioural domains (smoking, drinking, sexual
behaviour, drug taking, suicide, and stealing). Within each 80
figure, responses have been separated into the different levels of

% would breach
behavioural intensity for each behavioural domain. 60
Respondents demonstrated greater than 80% consensus that
confidentiality should be breached in 11 of the 68 vignettes
40
(16%). These 11 items are presented in Table 3. They reflect a
range of high-intensity risk behaviours, including drug taking, Using inhalants
Using hallucinogens
suicidal behaviour, and engaging in unprotected sex while 20
Using amphetamines
HIV+. The highest level of consensus about breaching confiden- Smoking marijuana
tiality was 96%. This was achieved in relation to breaching 0
confidentiality following an admission of a suicide attempt more
than once in the last month.
Respondents demonstrated greater than 80% consensus 100
about not breaching confidentiality in 28 of the 68 vignettes
(41%). These 28 items are presented in Table 4. The circum-
80
stances prompting consensus about not breaching confidential-
% would breach

ity included a range of low-risk behaviours such as smoking

cigarettes and engaging in sex with a steady girlfriend, as well as 60
Sex while HIV+
a range of higher risk behaviours at low intensities, such as
Sex with multiple partners
engaging in illicit drug taking once several months ago or binge 40 Sex with steady girlfriend
drinking once a month for several months. The highest level
of consensus reached about not breaching confidentiality was
20
98%. This was achieved in relation to two items: smoking a pack
of cigarettes and/or binge drinking alcohol once several months
ago. 0
once monthly weekly nearly daily
Thus, there were a large range of circumstances in which several for several for several for the
participants did not believe a disclosure about risk behaviour months ago months months last year
by an adolescent client necessitated a breach of confidentiality Frequency of risk behaviour
to the adolescents’ parents. These circumstances far outweighed
the number of situations in which consensus was reached about Figure 1 Percentage of Participants Who Would Breach Confidentiality,
breaching confidentiality. There were 29 vignettes (43%) in Depending on Intensity and Frequency/Duration of Smoking, Drinking, Drug
which participants did not reach 80% consensus about whether Taking, and Sexual Behaviour.
to breach confidentiality. Table 5 presents these 29 items.
The tendency to breach confidentiality to inform parents of risk
behaviours increased across all six behavioural domains as the
frequency, intensity, and duration of the behaviour increased. adolescents’ parents about risk behaviour. The focus of the study
was circumstances in which adolescents were posing a risk to
Discussion themselves, as opposed to situations in which another person
was posing a risk to the adolescent. The study replicated a
The current study aimed to examine the situations in which previous study of American psychologists, published in two
Australian psychologists would breach confidentiality with parts, that examined when psychologists would breach confi-
an adolescent client in order to disclose information to the dentiality with adolescent clients (Rae et al., 2002) and what

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Adolescents, risk behaviour and confidentiality RE Duncan et al.

100 months ago and one session of binge drinking several months
ago. The highest level of consensus reached about needing to
80 breach confidentiality was 96%, and this was achieved in rela-
tion to the vignette stating that a suicide attempt had occurred
% would breach

Stealing a car
more than once in the last month.
60 Breaking into homes
Stealing clothing It was more common for respondents to demonstrate consen-
sus about not needing to breach confidentiality than it was for
40 respondents to demonstrate consensus about breaching confi-
dentiality. Respondents reached consensus about not needing to
20 breach confidentiality in 41% of vignettes, whereas in only 16%
of vignettes was consensus reached about breaching confiden-
0 tiality. The most common outcome was therefore a situation in
which respondents failed to reach consensus about breaching or
not breaching confidentiality.
100 In 43% of the vignettes, respondents did not achieve con-
sensus about breaching or not breaching confidentiality. This
implies a significant degree of variation among respondents’
80
views regarding appropriate limits to confidentiality with ado-
% would breach

lescent clients engaged in risk behaviour. This disagreement

60
Suicide attempt
40
Suicide gesture
Suicide ideation
20
0 One possible explanation for the significant variation in
once over once several once during more than
a year ago months ago the last month once last month
Frequency of risk behaviour
Figure 2 Percentage of Participants Who Would Breach Confidentiality,
Depending on Intensity and Frequency/Duration of Stealing and Suicidal
Behaviour.
factors psychologists use in their decision-making process (Sul-
livan et al., 2002). The findings of the current study have simi-
larly been separated into two articles. This article presents
findings related to when Australian psychologists would breach
confidentiality with adolescent clients, while the findings about
the factors that Australian psychologists use in their decision-
making processes have been published separately (Duncan
et al., 2012).
To examine the circumstances in which Australian psycholo-
gists would breach confidentiality with adolescent clients,
respondents were presented with 68 variations of a vignette
in which a 15 year-old boy engaged in risk behaviour. The
vignettes covered six domains of risk behaviour (smoking,
drinking, sexual behaviour, drug taking, suicide, and stealing)
and varied in intensity, frequency and duration. For each
vignette, respondents were asked to indicate whether they
would breach confidentiality to inform the boy’s parents about
his behaviour. Consensus among respondents was defined as a
minimum of 80% agreement.
There was no vignette in which 100% consensus was
reached. The highest level of consensus reached about not
breaching confidentiality was 98%, and this was achieved in
relation to two vignettes: smoking a packet of cigarettes several
among respondents has also been found in past studies using
the same survey with American school counsellors. School
counsellors demonstrated agreement in relation to the most
high-risk behaviours, such as suicide attempts; but for less high-
risk behaviours, they demonstrated a distinct lack of agreement
(Moyer & Sullivan, 2008).
opinion demonstrated by respondents in the current study is
that Australian psychologists are uncertain about when to
breach confidentiality with an adolescent client to inform
parents about risk behaviour. That is, they are unclear about
precisely how to interpret “an immediate and specified risk of
harm” as specified in the APS Code of Ethics (p. 15). The
challenges associated with interpreting such statements have
also been discussed in previous literature regarding the notion
of “clear and imminent danger” that school counsellors in the
USA are advised to identify (Moyer & Sullivan, 2008).
If the difference in opinion among respondents in the current
study reflects a lack of knowledge among Australian psycho-
logists about when a breach of confidentiality is appropriate,
this would suggest a need for targeted training and support to
decrease the uncertainty and increase Australian psychologists’
understanding and confidence about appropriate limits to con-
fidentiality with adolescent clients (Isaacs & Stone, 2001; Moyer
& Sullivan, 2008; Sullivan & Moyer, 2008). Current guidelines
do not provide in-depth information about the types of circum-
stances that constitute harm, leaving individual psychologists
with the task of making their own professional judgments
(Isaacs & Stone, 2001). In these circumstances, where guidance
is not specific, it is therefore critical that appropriate supports
are in place. Processes and supports might include an opportu-
nity to seek advice from colleagues or a supervisor, to seek
assistance from a professional body, such as the APS, or to access
information about what other psychologists have decided in
similar circumstances. Younggren and Harris (2008) specifically
highlight the need for psychotherapists to engage in peer
consultation when confronted with confidentiality dilemmas.
It might also be important for psychologists to have thorough
training in “normal” adolescent development so that they have
an understanding of the range of risk behaviours that are

414 Australian Psychologist 48 (2013) 408–419

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RE Duncan et al. Adolescents, risk behaviour and confidentiality

Table 3 Circumstances in which Participants Demonstrated ⱖ80% Consensus that Confidentiality Should Be Breached to Inform Parents

Risk behaviour Level of frequency/duration % who would breach

confidentiality

Engaging in unprotected sex while HIV+ monthly for several months 87

weekly for several months 88
nearly daily for the last year 89
Using amphetamines nearly daily for the last year 80
Using inhalants nearly daily for the last year 83
Using hallucinogens nearly daily for the last year 82
Suicidal ideation (“I wish I was dead”) nearly daily for the last year 85
Suicide gesture (taking pills) once during the last month 87
more than once during last month 94
Suicide attempt (trying to hang himself) once during the last month 93
more than once during last month 96

Table 4 Circumstances in which Participants Demonstrated ⱖ80% Consensus that Confidentiality Should Not Be Breached to Inform Parents

Risk behaviour Level of frequency/duration % who would not breach

confidentiality

Smoking one cigarette once several months ago 97

monthly for several months 97
weekly for several months 96
nearly daily for the last year 92
Smoking more than a pack of cigarettes once several months ago 98
monthly for several months 95
weekly for several months 91
Engaging in sex with a steady girlfriend once several months ago 96
monthly for several months 91
weekly for several months 88
nearly daily for the last year 85
Engaging in sex with multiple partners once several months ago 94
monthly for several months 86
Drinking one drink once several months ago 97
monthly for several months 97
weekly for several months 90
Binge drinking once several months ago 98
monthly for several months 82
Smoking marijuana once several months ago 97
monthly for several months 82
Using amphetamines once several months ago 93
Using inhalants once several months ago 91
Using hallucinogens once several months ago 90
Suicidal ideation (“I wish I was dead”) once several months ago 83
Stealing clothing from a store once over a year ago 96
once several months ago 95
once during the last month 87
Stealing a car for a joyride with friends once over a year ago 83

common during this life stage in order to help them determine
whether a specific behaviour falls outside this norm.
A second possible explanation for the differences in opinion
demonstrated in the current study is that perhaps not all
scenarios in which an adolescent client is engaged in risk behav-
iour have a concrete and definitive “correct” response regarding
whether a breach of confidentiality is necessary. It might be that
for situations that are not at the extremes of high or low risk,
a decision about whether to breach confidentiality is depend-
ent on additional, contextual factors. The vignettes presented
within the survey were lacking in detail about contextual
factors. Thus, it is possible that individual respondents were
swayed about whether to breach confidentiality based on
personal assumptions made about the context. For example,

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Adolescents, risk behaviour and confidentiality RE Duncan et al.

Table 5 Circumstances in which Participants Demonstrated Significant Disagreementa about Whether Confidentiality Should be Breached to Inform Parents

Risk behaviour Level of frequency/duration % who would breach

confidentiality

Smoking more than a pack of cigarettes nearly daily for the last year 22
Engaging in sex with multiple partners weekly for several months 26
nearly daily for the last year 36
Engaging in unprotected sex while HIV+ once several months ago 73
Drinking one drink nearly daily for the last year 35
Binge drinking weekly for several months 39
nearly daily for the last year 70
Smoking marijuana weekly for several months 40
nearly daily for the last year 67
Using amphetamines monthly for several months 41
weekly for several months 65
Using inhalants monthly for several months 50
weekly for several months 71
Using hallucinogens monthly for several months 51
weekly for several months 71
Suicidal ideation monthly for several months 53
weekly for several months 74
Suicide gesture once over a year ago 38
once several months ago 56
Suicide attempt once over a year ago 54
once several months ago 72
Stealing clothing from store more than once during last month 32
Stealing a car for a joyride with friends once several months ago 17
once during the last month 24
more than once during last month 45
Breaking into homes and stealing valuables once over a year ago 21
once several months ago 30
once during the last month 47
more than once during last month 64

a
Significant disagreement is defined as <80% agreement.

respondents might have made assumptions about the quality of
the adolescent’s family relationships or how often similar
behaviour had been engaged in over the past.
As mentioned previously, a separate section of the survey
used in the current study asked respondents about the consid-
erations they use when making decisions about breaching con-
fidentiality with adolescent clients. Those findings indicated
that an extensive range of considerations are taken into
account (Duncan et al., 2012). Similar findings, demonstrating
that psychologists use a vast range of considerations when
making such decisions, have also been found in past studies
using the same survey (Sullivan & Moyer, 2008). Some of the
considerations used by psychologists include: how the family
would respond if told about the risk behaviour; the adolescent’s
level of competence; workplace policy; the protective factors
present in the adolescent’s life; and whether the adolescent
understands why a breach of confidentiality is necessary
(Duncan et al., 2012). Given this wide variety of contextual
factors that are used in the real world of psychological practice,
it seems plausible that the absence of detail about such factors
in the vignettes presented within the survey might have con-
tributed to respondents’ failure to reach consensus in response
to vignettes that were not situated at the extreme ends of high
or low risk. This lack of context associated with the vignettes
has previously been noted as a limitation of the survey (Rae
et al., 2009).
A third possible explanation for the differences in opinion
demonstrated in the current survey is simply that Australian
psychologists do in fact differ in their views about when it is
appropriate to breach confidentiality with adolescent clients.
There are many reasons why professional judgements about
when to breach confidentiality might differ. Potential mediators
might include age, gender, type of training, number of years
working as a psychologist, or theoretical orientation. Previous
research looking at some of these mediators has found little
evidence for the mediating influence of factors such as gender,
years of experience, or level of education (Isaacs & Stone, 2001;
Moyer & Sullivan, 2008). However, it has been shown that
paediatric psychologists in the USA appear to have a higher
tolerance for risk behaviours in adolescent clients (and thus a
decreased tendency to breach confidentiality) than school psy-
chologists in the USA (Rae et al., 2009) indicating that perhaps
work setting or professional qualification might serve as medi-
ating factors. Previous literature also highlights the fact that

416 Australian Psychologist 48 (2013) 408–419

© 2012 The Australian Psychological Society

RE Duncan et al.
when psychologists and counsellors are required to rely on their
own professional judgements, they are particularly vulnerable
to being influenced by their personal values and beliefs (Moyer
& Sullivan, 2008; Sullivan & Moyer, 2008).
If it is the case that the differences in opinion among respond-
ents in the current study reflect not a lack of knowledge and
not a lack of contextual detail within the vignettes, but rather
fundamental differences of opinion, the question that needs to
be addressed is, does this matter? If Australian psychologists
hold differing opinions about when it is appropriate to breach
confidentiality with adolescent clients, it is likely their practice
similarly differs. How important is it that psychological practice
regarding limits to confidentiality with adolescent clients is con-
sistent throughout Australia? This is not a question that can be
answered in this article, but it is one that certainly deserves
attention within the Australian psychological profession as a
whole.
Perhaps the two most important pieces of information
provided by the current study are that first, a range of circum-
stances exist in which the majority of Australian psychologists
are likely to breach confidentiality with an adolescent client,
and second, there are a range of scenarios in which practice is
likely to vary throughout Australia. Both of these findings high-
light the same critical fact; that Australian psychologists must
engage in clear and direct communication about their individual
limits to confidentiality with adolescent clients and their fami-
lies at the onset of therapy. In this way, the principles of both
transparency and informed consent are upheld. If clients have
been informed of their psychologists’ limits to confidentiality
at the onset of therapy, then, if they disclose information that
requires a breach of confidentiality, they are aware of the likely
consequences. This need for an initial explanation of the limits
to confidentiality is stipulated in current guidelines internation-
ally (American Psychological Association, 2002; Australian
Psychological Society, 2009; British Psychological Society, 2006;
Society for Adolescent Medicine, 2004b) and has also been
emphasised by the authors of the American studies that the
current study replicates (Rae et al., 2009).
The current study should be viewed in light of several limi-
tations. The vignettes presented to respondents all described a
male adolescent of 15 years of age. Thus, the results do not
necessarily extrapolate to female adolescent clients or adoles-
cents of different ages, and we were also not able to test for the
impact of client gender on participant responses. In the previous
study that we replicate here, vignettes of both males and
females were used, and there were two conditions in which
a significant difference was found related to gender. First,
respondents were more likely to find it ethical to breach confi-
dentiality for female smoking than they were for male smoking.
Second, they found it more ethical to breach confidentiality for
female sexual behaviour than for male sexual behaviour, but
only as the frequency/duration increased.
The vignettes presented in the current study were also all
hypothetical scenarios. Thus, the current study provides no
information about what Australian psychologists actually do
when faced with confidentiality dilemmas about adolescent
clients, only what they believe they would do. Future research
seeking to extend the current study might benefit from enquir-
ing about actual past cases in which psychologists have chosen
Australian Psychologist 48 (2013) 408–419
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17429544, 2013, 6, Downloaded from https://aps.onlinelibrary.wiley.com/doi/10.1111/ap.12002 by Monash University, Wiley Online Library on [23/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Adolescents, risk behaviour and confidentiality
to breach (or not to breach) confidentiality with adolescent
clients.
Conclusion
The current study aimed to document the circumstances in
which Australian psychologists would breach confidentiality
with an adolescent client in order to inform parents about risk
behaviour. It was more common for respondents to disagree
about whether a breach of confidentiality was necessary than it
was for respondents to reach consensus about the need to either
breach or not breach confidentiality. There are a range of poten-
tial explanations for this. It could mean that Australian psy-
chologists are uncertain about when it is appropriate to breach
confidentiality with adolescent clients, or it could mean that a
range of mediating factors or contextual details influence opin-
ions. It could also reflect a real and significant variety of opinion
currently existing in the Australian psychological profession
regarding appropriate limits to confidentiality with adolescent
clients. If this is the case, the profession must ask itself how
important consistency of practice is and whether more training
and guidance is required in this area. The findings of the current
study provide an important empirical resource for professionals
to use as a basis for comparison with their own views and
practice. The findings also highlight the need for the psychology
profession to maintain principles of transparency and informed
consent through a commitment to clear communication about
the limits to confidentiality at the onset of therapy and through-
out the therapeutic process.
Acknowledgements
Rony Duncan is partly supported through a Fellowship from
the Invergowrie Foundation. This study was supported by the
Operational Infrastructure Support Program of the Victorian
Government.
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