about his or her mental and physical health and re-
lated care. Confidentiality means allowing only those
dealing with the client’s care to have access to the in-
formation that the client divulges. Only under pre-
cisely defined conditions can third parties have access
to this information; for example, many states require
that staff report suspected child and elder abuse.
Adult clients can decide which family members,
if any, may be involved in treatment and may have
access to clinical information. Ideally the people close
to the client and responsible for his or her care are in-
volved. The client must decide, however, who will be
included. For the client to feel safe, boundaries must
be clear. The nurse must clearly state information
about who will have access to client assessment data
and progress evaluations. He or she should tell the
client that members of the mental health team share
appropriate information among themselves to pro-
vide consistent care and that only with the client’s
permission will they include a family member. If the
client has an appointed guardian, that person can re-
view client information and make treatment deci-
sions that are in the client’s best interest. For a child,
the parent or appointed guardian is allowed access to
information and can make treatment decisions as
outlined by the health care team.
The nurse must be alert if a client asks him or her
to keep a secret, because this information may relate
to the client’s harming himself or herself or others.
The nurse must avoid any promises to keep secrets.
If the nurse has promised not to tell before hearing the
message, he or she could be jeopardizing the client’s
trust. In most cases, even when the nurse refuses to
agree to keep information secret, the client will con-
tinue to relate issues anyway. The following is an ex-
ample of a good response to a client who is suicidal
but requests secrecy:
Client: “I am going to jump off the 14th floor of
my apartment building tonight, but please don’t tell
anyone.”
Nurse: “I cannot keep such a promise, especially
if it involves your safety. I sense you are feeling fright-
ened. The staff and I will help you stay safe.”
The Tarasoff vs. Regents of the University of Cal-
ifornia(1976) decision releases professionals from
privileged communication with their clients should a
client make a homicidal threat. The decision requires
the nurse to notify intended victims and police of such
a threat. In this circumstance, the nurse must report
the homicidal threat to the nursing supervisor and
attending physician so that both the police and in-
tended victim can be notified. This is called a duty to
warnand is discussed more fully in Chapter 9.
The nurse documents the client’s problems with
planned interventions. The client must understand
that the nurse will collect data about him or her that
helps in making a diagnosis, planning health care5 THERAPEUTICRELATIONSHIPS 99
the real problems. It may take several sessions until
the client believes that he or she can trust the nurse.
Nurse–Client Contracts.Although many clients have
had prior experiences in the mental health system,
the nurse must once again outline the responsibili-
ties of the nurse and client. At the outset, both nurse
and client should agree on these responsibilities in
an informal or verbal contract. In some instances, a
formal or written contract may be appropriate; ex-
amples include if a written contract has been neces-
sary in the past with the client or if the client “for-
gets” the agreed-on verbal contract.
The contract should state:
- Time, place, and length of sessions
- When sessions will terminate
- Who will be involved in the treatment plan
(family members, health team members) - Client responsibilities (arrive on time, end
on time) - Nurse’s responsibilities (arrive on time,
end on time, maintain confidentiality at all
times, evaluate progress with client, docu-
ment sessions)
Confidentiality.Confidentiality means respect-
ing the client’s right to keep private any information
Phases of nurse–client relationship