Duty to Report An Infectious Disease

— Tien Liang and  G. Andrew H. Benjamin

Three months into continuing treatment, a young woman who has a history of engaging in destructive relationships with men she meets through the Internet cancels a scheduled appointment because she has the flu.   Two weeks later, she appears in the next session quite agitated.  She reports that she received a phone call from the Department of Health of her state government. She was notified that Tom, someone with whom she broke up months ago, had been diagnosed with AIDS and that she may have been exposed.  She is convinced that she does not have AIDS; she had not engaged in any sexual relationship with Tom since they have separated.  She also has become sexually involved with John since breaking up with Tom.

Your practice disclosure statement that she read as part of the informed consent process indicated that under the laws of the State you are a mandatory reporter of the identities of clients with HIV/AIDS. At this later point in treatment, what should you discuss with your client in terms of limits of confidentiality and your duty to report?

Practice Tip 1

Each State or Province has different laws.  The duty to report clients that convey they have contracted HIV/AIDS exists in some jurisdictions.  Alas, this new duty appears to be emerging from the legislatures of more jurisdictions. In some of these jurisdictions, HIV/AIDS is not the only communicable disease a psychologist must report. Although it is beyond the scope of practice for psychologists to diagnose communicable diseases, psychologists are designated mandatory reporters when their clients state that they have contracted a communicable disease that is considered a public health hazard. 

Make sure you know whether the regulations in your jurisdiction apply to psychologists.  In some jurisdictions, all “health care” providers are mandatory reporters. Please call the volunteer specialists who serve in your State, Provincial, and Territorial Association Ethics Committees to determine whether a statute or regulation requires mandatory reporting of clients who have contracted HIV/AIDS. Or turn to a J.D. / Ph.D. trained clinical psychologist in your jurisdiction that knows the nuances about the laws related to psychological practice. Also, the free legal counsel provided by the two largest malpractice carriers that serve psychologists may be able to direct you to the law.

Practice Tip 2:

Each State and Province has different procedures for reporting. Become clear about the standard of practice that is required: 1) At what point in a communication from a client do you as a psychologist become a mandatory reporter; and 2) How is the duty to report discharged— in particular, who do you make the report, what constitutes the report, and in what period of time must you make the report?

Practice Tip 3

Your written disclosure statement and inform consent process alerts your potential clients about the limits to your being able to protect their confidential information, and provides each with an opportunity to check with their legal advisors before beginning psychotherapy.

A therapeutic alliance is founded on the informed consent process (Waitzkin, 1984). From the beginning of the professional relationship, to help the client make an informed decision about whether to pursue treatment, the psychologist informs the client about what confidential information must be disclosed in certain defined legal contexts. The laws related to all mandatory reporting duties and the duty to protect should be delineated clearly to the client. In part, this process forewarns the client about issues that would require disclosure, and if the MHP must act on the duty, forewarning the client can avoid the client’s feeling surprised and betrayed. Individuals seeking mental health services expect confidentiality (VandeCreek, Miars, & Herzog, 1987). The early transparency with clients encourages them to work with the MHP to remain within the confines of the law.

In addition, explicit dialogue about the disclosures leads to a more efficacious informed consent process (Pomerantz & Handelsman, 2004). Clients may not always read the informed consent document carefully and may skip the portion explaining when the law requires the psychologist to make a report; they may also feel uncomfortable about seeking clarification with a psychologist they have just met. Some of a client’s discomfort may be mitigated by the psychologist providing a very brief verbal highlight of the confidentiality section of the informed consent at the beginning of treatment.

Practice Tip 4

Be prepared in advance. Before encountering a situation in which you might have to report a communicable disease, make sure you know the specifics about what a client might expect from the agency receiving the report.  In this way, you can have an accurate discussion with your client when needed. Accurate information about the possible consequences of the report, provided in a matter of fact manner, can lead to the client feeling less anxious.  Talk with the public health services in your state to find out their procedures before you ever find yourself in a position of serving as a mandated reporter of a client with communicable disease.

Practice Tip 5

Protect your therapeutic alliance. If the mandatory reporting duty emerges, you have a solid foundation on which to launch an active collaboration in order to meet the reporting duty. The therapeutic alliance is one of the most critical factors in determining effective treatment outcome (Hovarth & Bedi, 2002).

Immediately upon any indications that you might have to report a communicable disease, remind the client of such a report being necessary under the law, and advise your client of the limits of confidentiality. If it is possible to discharge the duty by having the client make the report in your presence, discuss this approach as one option. Another option is for your client witnessing the call. In either case, you protect the therapeutic alliance by being present and able to respond to the client’s needs as you meet the legal duty.

Detail in advance of the call all of the questions that occur to your client about the possible consequences of the call. Attempt to obtain the answers to as many of the questions as possible during the call to the agency that receives the report. Sometimes you will need to speak to the supervisor because the first receiver of the call may not know all of the answers.

You can send correspondence to Tien Liang or Andy Benjamin or learn more about their backgrounds at:  http://www.antiochsea.edu/about/OurFaculty_list.html or http://depts.washington.edu/petp

References

Hovarth, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships that work (pp. 37-69). New York: Oxford University Press.

Pomerantz, A. M., & Handelsman, M. M. (2004). Informed consent revisited: An updated written question format. Professional Psychology: Research and Practice, 35, 201-205.

VandeCreek, L., Miars, R., & Herzog, C. (1987). Client anticipations and preferences for confidentiality of records. Journal of Counseling Psychology, 34, 62-67.

Waitzkin, H. (1984, November 2). Doctor-patient communication: Clinical implications of social scientific research. JAMA, 252, 2441-2446.