Name: Ethical Dilemma in Forensic Psychiatry: Involuntary Commitment & Confidentiality
Uploaded: 2026-02-19
Duration: 14 min 1 s
Description: SWK 6536: ADVANCED PRACTICUM SEMINAR II. Ethical Dilemma in Forensic Psychiatry.

SWK 6536: ADVANCED PRACTICUM SEMINAR II. Ethical Dilemma in Forensic Psychiatry. 

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PRACTICUM CONTEXT. Introduction & Background. Practicum Setting. 

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Kirby Forensic Psychiatric Center serves as a secure treatment facility for individuals involved in the criminal justice system who require specialized psychiatric care. The center operates at the intersection of mental health treatment and legal oversight, presenting unique ethical challenges for social work practice.

With over 3 years of experience working with forensic psychiatric populations, I have developed expertise in navigating complex clinical scenarios where patient autonomy, confidentiality, and safety concerns intersect with legal mandates and institutional protocols.

Forensic settings amplify ethical tensions because social workers must simultaneously serve multiple stakeholders —the patient, the institution, the legal system, and public safety.

Patient Rights: Confidentiality, autonomy, informed consent

Public Safety: Duty to warn/protect, risk assessment

Legal Obligations: Court mandates, institutional policies

"The forensic context transforms routine ethical considerations into high-stakes decisions where the consequences of error—whether failing to protect or breaching trust—can be profound and irreversible."

CLINICAL SCENARIO. Description of the Ethical Dilemma. 

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Experiencing paranoid delusions with fixed belief that others can read his mind and access private thoughts without consent

Documented history of self-harm behaviors during acute psychotic episodes, with recent escalation in threat perception

The patient reports believing that a peer on the unit is talking about him and expressing feelings of being threatened and watched. However, the patient has not made any specific verbal or behavioral threats toward the identified peer.

"He knows what I'm thinking. He's telling everyone. I can't trust anyone here."

When does perceived threat warrant intervention?

NASW CORE VALUES. Professional Values in Conflict. 

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Honor patient's right to self-determination and privacy in treatment decisions

Obligation to intervene when there is reasonable concern for safety

Therapeutic alliance depends on patient confidence in confidentiality

Legal and ethical obligation to breach confidentiality when safety is at risk

Right to confidentiality and autonomous decision-making in treatment

Professional duty to act when risk assessment indicates potential danger

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SELF-REFLECTION. Personal Values and Influences. Personal Beliefs About Confidentiality. 

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My personal values strongly emphasize respect for individual privacy and the sanctity of the therapeutic relationship. I believe that trust is the foundation of effective social work practice.

"Patients must feel safe to share their innermost thoughts without fear of judgment or disclosure."

Simultaneously, I hold a deep commitment to preventing harm and protecting vulnerable individuals. This value was shaped by experiences witnessing the consequences of unaddressed risk.

Responsibility to act when harm is foreseeable

Balancing individual rights with collective safety

Working in forensic psychiatry has fundamentally shaped my decision-making approach. The high-stakes environment requires:

Rapid risk assessment skills to evaluate potential threats

Integration of legal knowledge with clinical judgment

Comfort with uncertainty and ambiguity in complex cases

Perhaps the most significant influence on my practice has been the emphasis on collaborative decision-making through supervision.

Key Learning: No ethical decision should be made in isolation. Consultation provides perspective, identifies blind spots, and ensures comprehensive consideration of all factors.

RESPONSE FRAMEWORK. Immediate Reactions & Initial Approach. 

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The immediate response must center on comprehensive risk assessment to determine the level of danger.

Before making any decisions about confidentiality, immediate consultation is essential.

Psychiatrist, nursing, psychology, social work

Review applicable frameworks to ensure decisions are grounded in professional standards and legal requirements.

NASW Code of Ethics - Standards 1.01, 1.02, 1.07

NY State Law - Duty to warn/protect obligations

Agency Policies - Kirby Forensic Center protocols

Throughout the process, maintain commitment to transparency with the client whenever clinically appropriate.

Key Principle: Even when breaching confidentiality is necessary, explain the rationale to the patient to preserve trust.

Explain limits of confidentiality at intake

Involve patient in safety planning when possible

PROFESSIONAL STANDARDS. NASW Code of Ethics & Guidelines. 

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Social workers' primary responsibility is to promote the well-being of clients. In general, clients' interests are primary. However, social workers' responsibility to the larger society or specific legal obligations may limit clients' right to self-determination.

Application: Client well-being is paramount, but safety concerns may override confidentiality.

Social workers respect and promote the right of clients to self-determination and assist clients in their efforts to identify and clarify their goals. Social workers may limit clients' right to self-determination when actions pose a serious, foreseeable, and imminent risk.

Application: When safety is at risk, limits on confidentiality are justified.

Social workers should respect clients' right to privacy. Social workers should protect the confidentiality of all information obtained in the course of professional service, except for compelling professional reasons. The general expectation is that social workers will keep information confidential unless disclosure is necessary to prevent serious, foreseeable, and imminent harm.

Application: Confidentiality can be breached to prevent serious harm to the client or others.

Social workers should be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. Social workers should inform clients when a real or potential conflict of interest arises.

Application: Ensure decisions are based on professional standards, not personal bias.

These standards collectively establish that while confidentiality is a cornerstone of social work practice, the duty to protect individuals from serious harm takes precedence when there is clear and imminent danger. The NASW Code provides ethical justification for breaching confidentiality in forensic settings where safety concerns arise, supporting a balanced approach that respects both client rights and professional obligations to prevent harm.

INSTITUTIONAL FRAMEWORK. Agency Policies & Best Practices. 

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Kirby Forensic Psychiatric Center Protocols

Kirby operates under comprehensive policies designed to balance patient care with safety management. These protocols provide the operational framework for navigating ethical dilemmas.

Kirby employs evidence-based assessment tools to standardize risk evaluation and support objective decision-making.

Collaborative decisions are stronger decisions

LEGAL FRAMEWORK. Legal Considerations. Duty to Warn & Protect in NY State. 

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New York State recognizes the professional duty to protect potential victims when a client poses a serious threat of violence.

"Mental health professionals have a duty to take reasonable steps to protect identifiable potential victims when they know or should know of a patient's violent propensities."

Identifiable victim: Specific person or group threatened

Serious threat: Credible risk of significant harm

Established duty to warn/protect in California

Governs involuntary commitment & treatment

When a client poses a danger, social workers must navigate specific legal obligations that may override confidentiality.

Thoroughly assess risk and document findings

When appropriate, warn identifiable victims

Contact police when imminent danger exists

NY law emphasizes duty to protect over mere warning. This may include hospitalization, safety planning, or other interventions beyond notification.

CULTURAL COMPETENCE. Cultural Considerations. Recognizing Cultural Influences. 

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Cultural background profoundly shapes how individuals perceive mental health, privacy, and help-seeking . Understanding these influences is essential for ethical practice.

During intervention, it is crucial to respect and integrate the patient's cultural context into treatment planning and ethical decision-making.

Key Insight: Cultural competence is not about stereotyping but about individualized understanding of how culture shapes this particular patient's experience.

Ensure accurate communication across language barriers

Inquire about family involvement and decision-making

Each person's cultural identity is unique

Acknowledge fears about confidentiality breaches

Cultural humility enhances ethical practice

CLIENT RIGHTS. Informed Consent & Client Involvement. 

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Obtaining informed consent in forensic psychiatry presents unique challenges due to involuntary status, cognitive impairments, and the dual role of treatment and evaluation.

Assess patient's ability to understand information and make reasoned decisions. Document capacity assessment.

Clients must understand when and why confidentiality may be breached, particularly in forensic settings where safety concerns are paramount.

"I want you to know that what we discuss is generally private. However, if you tell me something that makes me concerned about your safety or the safety of others, I may need to share that information with the treatment team."

Empowering clients to understand their rights and risks promotes autonomy and strengthens the therapeutic alliance, even in mandated treatment contexts.

Discuss rights, risks, and treatment options in accessible language

Create space for patients to ask questions and express concerns

Involve patients in safety planning and treatment decisions when possible

Even when breaching confidentiality is necessary, transparent communication about the rationale and process can preserve trust and model ethical decision-making for the patient.

DECISION ANALYSIS. Available Options & Analysis. 1. 

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Maintain current treatment approach without breaching confidentiality, while intensifying observation and assessment.

• Potential liability if violence occurs

Alert staff and relevant authorities about the patient's expressed concerns and potential risk, implementing safety protocols.

Collaborate with the patient to develop a safety plan, involving them in identifying triggers and coping strategies.

• May not be feasible in acute psychosis

The optimal approach often involves combining elements of all three options : intensify monitoring while engaging the patient in safety planning, and be prepared to breach confidentiality if risk assessment indicates imminent danger. This balanced approach respects autonomy while fulfilling the duty to protect, adapting to the evolving clinical situation.

RISK MITIGATION. Steps to Minimize Risks. Collaborate with Supervisors & Team. 

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No ethical decision in forensic settings should be made in isolation. Collaborative consultation provides multiple perspectives and reduces individual liability.

Immediate supervisor consultation - Discuss concerns and options

Multidisciplinary team input - Gather psychiatric, nursing, psychology perspectives

Document consultation - Record who was consulted and their recommendations

Thorough documentation is essential for legal protection and professional accountability. Clear records demonstrate that decisions were thoughtful and evidence-based.

• Rationale for chosen course of action

Follow Agency Policies & Legal Requirements

Adherence to established protocols and legal standards provides a framework for decision-making and demonstrates professional competence.

Understand legal obligations in your jurisdiction

Apply standards consistently across similar cases

Risk is not static. Ongoing assessment allows for adjustment of interventions as the situation evolves, ensuring that responses remain appropriate to the current level of risk.

CLINICAL APPLICATION. Practice Context & Client Interaction. 

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How Forensic Setting Influences Decisions

The forensic psychiatric environment creates a unique decision-making context that differs significantly from community mental health settings.

• Controlled access to potential victims

In forensic settings, supervision is not optional—it is an essential safeguard for both clients and practitioners. Complex ethical decisions demand experienced guidance.

Provides perspective from experienced clinicians

Identifies blind spots and alternative approaches

Documents that decision was not made in isolation

Maintaining open communication with clients about clinical decisions preserves trust and models ethical practice.

When breaching confidentiality, explain why it is necessary and what will happen

Include patient in safety planning and decision-making process

Acknowledge the impact on trust and work to rebuild the therapeutic alliance

Transparency builds trust, even in difficult moments

SUPPORT SYSTEMS. Resources in Decision-Making. Supervision & Peer Consultation. 

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Clinical supervision and peer consultation provide invaluable support for navigating ethical dilemmas. These resources offer diverse perspectives and reduce the isolation of difficult decisions.

Scholarly literature provides evidence-based guidance for ethical decision-making. Key references inform practice and support clinical judgment.

Granich, S. (2012). Duty to warn, duty to protect. Social Work Today.

Provides practical guidance on navigating duty to warn/protect obligations while maintaining therapeutic relationships.

The NASW Code of Ethics serves as the foundational guide for social work practice, providing clear standards for ethical conduct and decision-making.

Agency policies provide operational guidance specific to the practice setting, translating broad ethical principles into concrete procedures.

PROFESSIONAL DEVELOPMENT. Reflection & Personal Growth. 

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My practicum at Kirby Forensic Psychiatric Center has been a profound learning experience , challenging me to integrate theoretical knowledge with complex real-world scenarios.

• Ethical dilemmas are rarely black and white

• Consultation is essential, not optional

• Deeper understanding of legal context

Individual supervision has been instrumental in my development, providing a safe space to process difficult cases and receive guidance from experienced clinicians.

"Supervision has taught me that ethical competence is not about having all the answers, but about knowing how to seek guidance and reflect on complex situations."

This experience has fundamentally shaped my approach to social work practice and my professional identity.

Integrated approach balancing multiple values and obligations

Recognition that complex decisions require team input

Understanding of how law shapes clinical practice

I am committed to a career at Kirby Forensic Psychiatric Center, where I can continue to grow as an ethical practitioner and contribute to this challenging but vital work.

REGULATORY INSIGHTS. NYC Licensing Board Violations. 

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Review of NY State licensing enforcement actions reveals common patterns in violations related to confidentiality and safety in mental health practice.

Source: NY State Education Department Office of Professions - Disciplinary Actions Database

Social worker disclosed client information to family member without consent, violating Standard 1.07.

Clinician failed to report credible threat of violence, resulting in harm to third party.

Analysis of enforcement actions reveals which NASW ethical standards are most frequently implicated in disciplinary cases.

Standard 1.07 - Privacy & Confidentiality

Most commonly cited in violations involving unauthorized disclosures

Implicated when failure to act results in client harm

Violations related to inadequate or falsified records

Reviewing disciplinary actions reinforces the importance of strict adherence to ethical standards , thorough documentation, and proactive consultation. These cases serve as cautionary examples of the consequences when professional standards are not maintained.

CONCLUSION. Balancing Ethical Principles in Forensic Practice. 

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Balancing Ethical Principles in Forensic Practice

Ethical practice in forensic psychiatry requires thoughtful navigation of competing obligations—respecting patient autonomy while fulfilling the duty to protect, maintaining confidentiality while ensuring safety.

Success depends on collaboration, consultation, and commitment to professional standards.

Committed to ethical social work practice in forensic settings

Ethical Dilemma in Forensic Psychiatry: Involuntary Commitment & Confidentiality

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