Confidentiality limits and risk / Safeguarding and Risk Management

Appendix to Safeguarding and Risk Management Policy | Atrium Prison Counselling Service

Confidentiality and the practitioner’s role

All our counsellors and clinical trainers abide by a professional Code of Practice and Ethics, which ensures the confidentiality of sessions. Other members of staff may need access to your records for administration purposes. All Atrium staff are bound by our own confidentiality agreement and the requirements of the General Data Protection Regulations (GDPR) 2018. Please refer to full policies on safe guarding, confidentiality and bullying and harassment to ensure an overview of what process to follow.

Limits of confidentiality in Talking therapies Atrium Services

Who is this for?

This process document is to support Atrium staff in developing good and safe practice whilst working in the forensic setting. The statement below can be shared with clients in the initial assessment. It is to read to the clients during the contract and confidentiality discussion. We assume terms are accepted unless the client tells us otherwise before service commences and you must ensure the contract is signed by the client and yourself before proceeding with the assessment. The practitioner will note on System 1 and CORE-Net if these terms have not been accepted as this is a reason for withdrawal of service.

‘Atrium will uphold the confidentiality of our sessions together, under normal circumstances. No details that would identify you or the issues discussed will be revealed. An Atrium practitioner will need to disclose personal information where there is a threat of serious harm to yourself or others. In these circumstances, you will normally be made aware of our obligations to break confidentiality, where upon we will notify the relevant parties such as Healthcare, Senior Officers, Safer custody and/or Security and take appropriate action to ensure yours and others safety. I will let you know where possible the action I am taking under our safeguarding policy and will ask for you to work with me in doing this. However, we do not need your permission if there is a clear and present risk to yourself or others. If at any time you appear to be moving towards a discussion that will leave you to disclose information that I am required to report to the prison or the police liaison, I will remind you of the limits of confidentiality in our work.’

Why is it important to set out our limits to confidentiality important?

It is very important to set out confidentiality with prison clients transparently at the beginning of our work. This openness ensures that clients can evaluate the safe space available for counselling, build trust with the practitioner or choose not to enter this relationship. It is also important to be clear of how to prevent disclosures that may bring risk to the client, the therapy relationship, the wider prison system, and Atrium services.

When a client makes a disclosure that activates our safeguarding processes there is always a consequence

• to the client (potential investigations by police, involvement of escalations of prison involvements)
• to the therapy relationship (trust reduces and the relationship changes to a system collective accountability, risk management intervention and the therapy may have to be suspended or stopped)
• to the practitioner (the client may blame the practitioner for having to start safeguarding processes which have a negative impact on his life in prison/sentence etc which could put the safety of the practitioner at risk)
• to others (the risk might bring pre-emptive action by those who have been indicated at risk or by the systems charged with their safety which could escalate responses)

Safeguarding actions create less safety in the system temporarily and increases the risk to the client when the consequences begin to be anticipated or actualised leading potentially to increased distress to the client. This can lead to an increasing risk of self-harm and suicide and vulnerability which might be noticed and exploited by others. The practitioner needs to be discerning and transparent in the recognising of a potential disclosure which could be harmful and clear on how both the therapist and the prison will manage the potential increased risk disclosure may have.

Disclosure and Reporting.

If a client discloses thoughts and/or intentions relating to self-harm or suicidal ideation you will engage in discussion with them immediately within the session, engaging them in a risk awareness formulation utilising your CASE training and safeguarding practice.

• What are their thoughts?
• Is there a history of attempts or self- harm or impulsivity?
• How recent? Is there escalation of frequency or intensity?
• Do they have a plan?
• Where are they likely to attempt self-harm or suicide?
• When are they likely to attempt self-harm or suicide?
• How are they likely to attempt self-harm or suicide?
• How have they attempted this in the past?

Record any disclosure of thoughts of self-harm or suicide in their System 1 healthcare record within session notes, the current risk and what action you have taken. If you believe there is a clear and present risk an ACCT document must be opened, and this safety process must followed (see SASH process for further information). Reporting risk level associated with self-harm and suicide in every session note is best practice, for example

#(client number) Atrium Counselling session. Client was clear and focused throughout session and reported no thoughts of self harm or suicide…(proceed with session notes).

OR

#(client number) Atrium Counselling session. Client was clear and reported no thoughts of suicide. However the client presented as less focused than usual and reported thoughts of self-harm. We explored his thoughts in session, and I am satisfied there is no immediate risk to client as self-harm thoughts relate to future events. No ACCT document opened as no immediate risk, observation book entry made and S.O officer made aware of future risk. Plan: to monitor ongoing risk weekly and liaise with MHT team regarding future risk.

If a client makes a threat to others within the counselling session, exploring this with them could be appropriate and beneficial to the client and the work you are engaged in. The client could be letting of steam and have no intention to act upon what is said or be venting against the world or past wrongs in general as part of their processing of their feelings and experience. However you must consider the nature or specificity of threats within the context of the conversation and always inform the client of your duty of care to them and others within any risk assessment.

For example, the practitioner might also frame the conversation by informing the client of your concerns for his safety if he were to act out his stated threat and relay some realities of the consequences of these actions under the prison system. If the client wants to proceed from a hypothetical situation to firming up and deepening threats then you can close him down, consider reminding him again that you will have to act on the disclosure to close him down, taking your leave as this is not what the counselling space is for.

Having an understanding of your clients risk is essential. It is not disclosure of confidential information by talking with officers on the landing about what kind of prisoner he is to gain an overview of his state of mind or threat level. You do not disclose the nature or content of your counselling sessions or what has been said rather you are gaining information to ascertain the clients overall risk and whether his threats may be realised. However, if your feeling is there is a risk and the officers report he is a good prisoner, go with your feeling always and take the procedural safeguarding actions.

If a client has made a direct threat to another during your session, you have a responsibility to the prison to report this. If you are aware of potential for harm coming to others and the client reports that he informed you of his intentions prior to the act, this will lead to consequences for you to explain why you did report this to security and the house block staff. Be mindful for every incident and potential harm. It is not just your client and another individual with the potential to come to harm, it is also the risk to other prisoners nearby, staff and the incident responding staff.

If the client presents as a risk to others, the practitioner should determine whether it is safe to inform them of your intention to report this concern. If you feel it is not safe, then do not disclose your intentions. Be aware that you have discussed the confidentiality agreement with the client during assessment in the scope and limits of confidentiality and it is the client’s explicit choice to discuss this in sessions.

Expectations of Clinician

• Always record all correspondence with a client on System 1
• Refer client to appropriate services if risk deems it necessary
• Only divulge relevant and necessary information regarding client’s risk when required to. No other information is to be divulged.
• Read and understand all protocols and the overlaps for Atrium, NHS eg. Oxleas
• Let your manager know of your concerns and utilise Supervision in all disclosure work
• Work with your client through disclosure, discussing limits of confidentiality throughout and the understandable impact this has on your therapeutic relationship.