Confidentiality is a cornerstone of the therapeutic relationship. The ethics of my profession require that all communication between my patients and me remains confidential. In other words, I cannot disclose the information a patient reveals in session, or my own impressions about a patient, to anyone without the patient’s explicit written consent. Of course, there are exceptions to the rule. I am a mandated reporter of child abuse, and if a patient is imminently suicidal or homicidal, I have a duty to notify the appropriate parties in order to save the patient’s life and protect the public. But these scenarios are relatively uncommon.
Undoubtedly, confidentiality is an important, if not essential, therapeutic tool. Patients are far more likely to enter therapy, and to be completely honest and forthcoming in therapy, when they know that “what happens in therapy stays in therapy.” I am honored and humbled, though not necessarily surprised, when a patient tells me that I am the first person she has ever told about a particular trauma, event, thought, or feeling. A therapist’s office is a safe place in which a patient can express anything and everything without fear of judgment, alienation, or other negative repercussions. Through this vulnerability and brutal honesty comes an opportunity for growth and meaningful change.
However, confidentiality is not without its problems. For example, psychologists often struggle with decisions as to whether to disclose information about adolescent patients to their parents. On the one hand, parents have a legal right to obtain health care information regarding their child, and they are technically the “holders” of any privileged communication between their child and her therapist. On the other hand, adolescents can undoubtedly benefit from discussing certain personal issues with a nonjudgmental third party outside their family, and they are less likely to raise such issues with their therapist if they know that the information will get back to mom and dad.
I know of some psychologists who share very little with the parents of their adolescent patients. After all, they argue, the primary developmental tasks of adolescence include separation from family and establishment of an independent identity. These psychologists believe that they are respecting the adolescent’s burgeoning sense of identity by excluding parents from treatment. They also believe that they are nurturing the therapeutic relationship by refusing to disclose all but the most essential information to an adolescent’s parents. Many of these therapists believe that the parents are guilty of causing or contributing to their child’s problems, and thus are best kept out of the treatment picture. As a result, many parents of adolescent patients are relegated to the role of chauffeur. They drive their child to her appointments and pay for her treatment without ever knowing what is going on in those sessions. Imagine how disempowering it must feel for a parent to be relegated to such a role.
To be sure, psychologists who practice this way make many valid points. However, I have a different perspective on my role as a therapist and on the role confidentiality plays in my work with adolescent patients. Consequently, I approach the issue of confidentiality with adolescent patients differently. Empirical research has demonstrated, and my own clinical experience has confirmed, that adolescent treatment generally works best when parents are fully informed and actively involved, and I communicate this point to my adolescent patients and their parents at the start of our work together. I am relatively unconcerned when I meet an adolescent patient who lacks insight or motivation or who resists treatment. I am very concerned when the parents of an adolescent patient are unwilling, unmotivated, or unable to play an active role in their child’s treatment.
When I work with adolescents with relatively normal social or developmental concerns (e.g., grief, problems with friends, sexuality, stress management, body dissatisfaction), parents play an important, though relatively minor, role in treatment. In these cases, the work is primarily between the adolescent and me. Even so, I involve parents in the initial evaluation, treatment planning, and discharge planning; I provide them with empirical literature on their child’s problem and the treatment approach I am using; I provide them with guidance as to how they can support their child at home; and I invite them to call me or schedule an appointment with me at any time if they have questions or concerns about their child.
In my work with adolescents with mental illnesses, parents play a central role as indispensable members of the treatment team. I take an authoritative stance regarding my knowledge of, say, major depression or anorexia nervosa, while also maintaining humility by respecting parents’ judgment and intuition regarding their child. I may be the expert on mental health, but they are the experts on their child.
Adolescents who are struggling with serious mental illnesses, such as bipolar disorder, major depression, anorexia nervosa, and bulimia nervosa, require treatment which is more intensive and more comprehensive. These patients need their parents to play an active role in managing their symptoms and creating an environment which is conducive to recovery. In order for parents to do this, they need to be informed about their child’s symptoms and progress. While I certainly do not share everything a teenage patient says in therapy with her parents, I do provide her parents with the information they need in order to help her get better.
The parents of adolescents with mental illnesses are often overly stressed, worried, isolated, and confused. These parents need considerable support, encouragement, and guidance as they learn to cope with their child’s illness and support her through her recovery. This one of the reasons why I am so fond of family-based treatment: I get to empower the family to support the patient, drawing upon the parents’ intimate knowledge of and investment in their child. Instead of pulling the patient away from her family, I strengthen her natural support system, which makes intuitive sense to me. After all, therapy is time-limited. Family is forever.
Family members are also vital in preventing relapse, as they are generally the first people to notice a change in their child’s mood or behavior. Equipped with the right knowledge and skills, parents can intervene immediately and help to pull their child back from the brink of relapse, often preventing the need for future treatment.
Does involving family members in treatment damage my relationship with my adolescent patients? In the short term, it often does. Keep in mind, though, that some families bring their adolescents to me after an unsuccessful course of traditional individual therapy in which the patient had a very special, exclusive relationship with her therapist (who may have implicated her parents in the etiology of her problems) but made no meaningful progress whatsoever. My therapeutic relationship with adolescent patients is certainly important, but it is far less important than strengthening her relationship with her family and taking the necessary steps to help her recover. As adolescent patients progress through recovery and gain more insight, they gain trust in me and in their parents. They gain faith in the recovery process, and most of them are grateful for the fact that their parents and I worked collaboratively to help them. As much as they may resist it, adolescents need boundaries and limits, and they need adults to work together on their behalf.
By involving parents so heavily in an adolescent’s treatment, am I disrupting the processes of separation and individuation? In the short term, yes. I would argue, however, that cutting, starving oneself, engaging in unprotected sex, and throwing up after meals are not acceptable ways of exerting control or establishing identity. The supposition that a certain unhealthy behavior serves a valuable emotional or developmental purpose does not justify allowing that behavior to go unchecked. It is the mental illness which hinders adolescent development, not the treatment. Adolescents struggling with crippling depression or anxiety, erratic mood swings, self-injury, or life-threatening eating disorders are unlikely to blossom into well-adjusted, independent young adults without significant support. Empowering an adolescent’s parents to help her overcome a mental illness is ultimately very respectful of adolescent development – it allows the patient to recover within the safety and security of her natural environment so that she may one day live independently, unencumbered by mental illness.
For these reasons, my relationship with the parents is just as important as my relationship with the adolescent patient. Parents need to trust my judgment and treatment methods. They are, after all, entrusting me with their child’s health and bright future. I believe that I earn parents’ trust by maintaining open lines of communication between us, by providing them with empirically-sound literature on their child’s condition and the treatment approach we are taking, by respecting their parental instincts and taking seriously their experiences with their child, by supporting them emotionally, by absolving them of guilt and self-blame for their child’s disorder, and by empowering them to take constructive action.
What a wonderful and refreshing perspective!!!!!
I would like to share this with every clinician out there, see who agrees, and then for those who do not ask “why?”
disclaimer: not a clinician
my daughter is currently in residential treatment at the renfrew center in philly. on friday evenings, there is a multiple-family group, where families and residents gather to freely chat, ask questions, voice concerns, etc.
the most mentioned issue amongst the residents, was trust. typically, it was loss of trust with a parent. i think parents with children who are challenged by eating disorders should know from the very start – trust was already an issue for your child, long before any breach. my thought on trust is this: if you have to snoop through a journal, or peek through drawers in order to figure out what your child is doing, youre not paying enough attention.
Thanks, Laura. Feel free to share this post with whomever you like. I would bet that the clinicians who don’t agree with me on this issue would have the following reasons and bases for disagreement, which I touched upon in the post:
1.) Developmentally, adolescents need to separate from their parents and establish their own identity
2.) Therapy works best when the adolescent has complete trust in the therapist and knows the therapist is “on their side”
3.) The therapeutic relationship is of utmost importance, and sharing info with parents undermines the therapist’s relationship with the adolescent
4.) The child’s problems are, at least partially, a result of “helicopter parenting,” overprotectiveness, parental pathology, neglect, enmeshment, or other disturbed patterns of of family interaction
5.) Parents are at best unnecessary and at worst counterproductive in the treatment of their adolescent children
6.) Adolescents need to be empowered to “own” their recovery
These points are generally based on abstract theory, not empirical fact or rational analysis of what really works. I disagree entirely with points 3 and 5. Point 4 may have some merit in certain cases (parents who are abusive, neglectful, or addicted inflict great harm on their children and can interfere with the process of recovery) but this is relatively rare among the patients I treat. I agree with points 1, 2, and 6 in the abstract, but I would argue that my approach ultimately demonstrates that I AM on the patients side (NOT the side of their illness) and ultimately, after successful treatment, leads to a healthy, developmentally appropriate separation from parents, an establishment of an individual identity, and an ability to “own” one’s recovery.
This is very interesting and I think you raise several good points. I would take issue, however, with the assertion that parents are the holders of any privileged communication between their child and the child’s therapists. This may be true in the state where you practice, but it is certainly not true in many states (for example NM where I practice law). In some states, the adolescent not the parent has the right to consent to mental health treatment and is the “owner” of information regarding their mental health and treatment. I think this needs to be made clear to parents and adolescents.
I definitely agree that when the adolescent’s natural support system is that adolescent’s family, it makes sense to try and include the family in ways that will be beneficial to helping the young person recover and avoid relapse. However, for many young people, such as the adolescents I represent, their family is not functioning as a support system and in many cases, the family dynamic has so broken down that these families are not able to support the young person. In these cases it is unfair to immediately require that these young people engage with families who are incapable and often unwilling to provide the necessary support.
While I agree that families should be engaged and educated and involved when a family member (regardless of the family member’s age) has a mental illness, I also think there is an assumption that all adolescents have available families who are able to step up and take on a significant role. And this is sadly just not true. I don’t want to cut families out of the picture nor would I suggest that a family must be “perfect” to be empowered to help an adolescent struggling with a mental illness. But I think it is a misconception to assume that the family is always the adolescent’s “natural environment.”
I do commend you for outreaching to parents and providing them with empirical up-to-date information about their child’s condition because I think so often parents are denied this information.
I wonder however, how you approach the issue of talking with parent with your adolescent patients. Is this something you discuss with them up front? Do you explain what information will be kept confidential and what you propose to share with the parents? Do you discuss the reasons why it might be beneficial to share this information with parents?
Thanks again for you work and for this thoughtful post on the topic.
Dear Jessie,
Thanks for your thoughtful response. You raise a good point about states differing as to whether the parents or adolescents are the holders of confidential information. I agree completely that not all families are willing or able to engage in therapy or support their adolescent, and this is a very unfortunate reality. It sounds as though you and I may work with very different types of families, though. The vast majority of the adolescent patients I treat have dedicated parents who are ready, willing, and able to support them through treatment. Of course, I deal with a self-selecting population: my adolescent patients come to me because their parents are very concerned about them and want to do whatever it takes to help them recover. It is the parents who search for an appropriate therapist, find me, call me, and initiate the treatment process. Many, if not most, of these parents have mental illnesses of their own, as most mental illnesses have a strong genetic component, but in my experience this does not prevent parents from playing an active and positive role in their child’s treatment.
In regards to your question about how I address confidentiality with adolescents and their parents – I spell out the issue of confidentiality and its limits in a detailed Parental Consent for Adolescent Treatment form as well as an Adolescent Assent for Treatment form that parents and adolescent patients sign prior to the initial evaluation. I discuss the issue of confidentiality with adolescents and their parents at the start of treatment and as often as necessary throughout the course of treatment. I make it clear to adolescents that there are certain issues that will remain private between the two of us and other issues that I need to tell their parents about, and I explain why it is important to tell their parents about certain issues (generally it is so their parents can help them with these issues). The issue of what to disclose to parents and what not to disclose is not black and white – in many cases it depends largely on the nature of the adolescent’s illness and my clinical judgment depending on my knowledge of the particular adolescent and parent in question. In my experience, most adolescents understand this policy, and most parents are very grateful for it.
Thank you, Dr. Ravin, for this helpful post.
In California, where I practice law, therapists are required by statute to obtain the informed consent of parents in order to provide treatment to minors for mental health disorders. While exceptions are written into the law, they are narrow and generally involve situations where, for example, the family environment is abusive or severely neglectful.
Although there is very little guidance in the California law, it seems to me that the intent behind the statute is to require full disclosure to parents of the nature of the diagnosis, the proposed treatment, evidence supporting the treatment models under consideration, and other relevant facts that are necessary for the parents to make an informed decision. If the therapist is aware of facts that are relevant to the decision concerning the kind of treatment to be provided, and does not disclose those facts to the parents, then arguably any consent given was not informed.
While of course some families are abusive or neglectful, I think the burden of persuasion should be on any therapist who would choose to exclude families from treatment. In the case of anorexia nervosa, for example, there is no evidence that one-hour per week sessions of individual therapy are as effective as family-based refeeding around the clock, every day. Furthermore, I think any therapist should be extremely reluctant to recommend that family based treatment not be used. After all, how is a therapist to really know whether the family will be an effective support system? Unless family-based therapy is tried, there’s no reliable way for the therapist to know in advance. I suspect some therapists try to determine whether involvement of the family would be helpful based solely on how the patient describes his or her family relationships. But that approach assumes that the anorexic patient is able to objectively and accurately describe the relatinships within the family and fails to account for the disorted thinking that characterizes the illness. It also presumes that the therapist is free of distorted thinking and is able to make an objective decision. Given abuses that have occurred in the past when mentally ill patients have been isolated from their loved ones, I think that involving families is, except in rare cases, not only the more effective therapeutic model but also the approach most likely to safeguard the rights and the interests of the patient.
Dr Ravin how refreshing to read your blog. Another point on this same issue that irritates me is that many professionals think that “confidentiality” excludes being able to speak to a parent AT ALLl. There is no break in confidentiality to get feedback FROM the parents. This way at the very least, the therapist might get a clearer picture of what is going on.
I know as a health professional in another field I view things very differently if an adolescent is making no progress but the parent tells me they aren’t practising at home. This is opposed to the no progress but everyone working together so another look at treatment and approach would be required.
Hello from Russia!
Can I quote a post in your blog with the link to you?
Adolescent psychotherapy has only recently taken hold as distinct from either child or adult psychotherapy. I believe that it is a good thing to share the information with the parents.