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Teens and Confidentiality in Counseling

Teens and Confidentiality in CounselingParental involvement is a key ingredient in kid client success in therapy. What this looks like will depend on your child and his/her treatment plan, your practical ability to be involved (are you a noncustodial parent? Is your child receiving services at school?) and the therapist. But at the very least, you and your child’s therapist should be communicating regularly.

Depending on the child, the parents and the treatment goals, I include parents in the following ways:

  • Parents attend sessions with their child (this is common with young children and with children who are struggling with attachment);
  • Parents come in for the first or last few minutes of session;
  • Meeting with parents separately before or after the child’s session;
  • Scheduling separate sessions with parents when needed and appropriate;
  • Arranging for phone calls to check in.

I like kid feedback for how parents should be involved, particularly with teenagers who are navigating the developmentally appropriate need to separate along with the necessary support from parents. Sometimes this means helping the teen figure out how they want to talk to parents about something and then inviting parents to session to help mediate a discussion.

I go over confidentiality with parents and teens in session with the understanding that we will all respect the teen’s privacy in the counseling relationship but that the adults will keep her safety paramount in decision-making around what to share. When kids are struggling in a gray area, I always encourage them to invite parents to the discussion but I won’t go over their heads and tell secrets unless I’m concerned for their safety.

Here’s the Ohio ACLU publication about minors and their rights. The part about counseling (this is a PDF file) starts at page 40: Your Health and the Law: A Guide for Teens.

From the file:

A minor who is at least 14 years old can request outpatient care without notifying a parent as long as the treatment does not include medication. However, such care is limited to six sessions or 30 days, whichever comes first. After that, the care must stop or the parents must be informed and must consent in order for treatment to continue. During the first six sessions or 30 days, the parents will not be informed of the treatment unless the teen consents or the care provider feels the minor is likely to harm someone. Still, before the parents can be informed, the care provider must first tell the teen that the parents will be notified.

I have not had a teen call and ask for counseling on her own but I have had other loving adults (relatives or family friends) call me to find out if they can bring the teen to counseling without parental consent. I always explain how the law works and explain that except in cases where parental involvement would be dangerous to the child, it’s really best to have parents be a part of counseling.

There are guidelines around counseling teens and maintaining confidentiality. As a counselor practicing in Ohio, my ethical guidelines come from Ohio’s Counselor, Social Worker, and Marriage and Family Therapist board and my professional organization, the American Counseling Association. Both these entities recognize that teen confidentiality is a gray area. The ACA and their sister organizations for social workers and other therapists regularly publish articles and papers on the topic.
Here’s a handful for you to check out:

As you can see, there are not definitive answers because these topics are complex and so very individual. How I might, for example, handle it if a client tells me s/he is sexually active will depend on many things including but not limited to:

  • Why the teen is in counseling in the first place;
  • With whom they are being sexually active (is it consensual? Is it legal?);
  • How old the teen is (there’s a big difference between a 13 year old and a 17 year old);
  • The family’s values around sexual activity;
  • The circumstances surrounding the sexual activity (are there pressing concerns about safety?).

My first priority is always first and foremost safety but I recognize my ideas about safety may be different than the families. For example, say I learn that a 17-year old after careful consideration and planning decides to access birth control and have sex with her long-term partner. Perhaps she comes from a strict, conservative family whose religious beliefs condemn premarital sex. I am unlikely to break confidentiality under those circumstances.

I say this to encourage parents to talk to their teen’s counselor to make sure that they understand each other. If you want a counselor who would break confidentiality then I’m not the right person to work with your teen. It’s best we all know this ahead of time.

That said, I do not ever encourage teens to lie and I do not side with them against parents.

Finally, when confronted with a sticky situation I seek supervision, meaning I go to my peers and my mentors to get feedback when I’m not sure. While maintaining confidentiality about the individual and the family, I ask for help and document these efforts accordingly. It’s dangerous for any therapist to operate in a vacuum and I am fortunate to have great counselors available to me to answer questions and help me examine ethical practice as it applies to the complicated reality that is counseling kids and teens.

Crying in front of your counselor

Crying In Front of Your CounselorI generally don’t think that your therapist’s personal experiences can tell you whether or not he or she will be a good therapist or the right therapist for you but there is one exception to this: I think every therapist ought to have had his or her own therapy. Not just to work through our stuff (‘cuz we all have stuff), but to intimately know the vulnerability of pouring your heart out to a stranger who is getting paid to listen to you.

Some of us decide to come see a counselor because we have thoughtfully considered our options with logic and care and we have decided that therapy makes the most sense. That’s some of us. But most of us come because we are desperate and we need things to change; most of us come because we’re in crisis. So we come, shaken and perhaps scared and perhaps defensive and we sit down in front of someone we have never met and who we might be afraid will judge us and find us wanting, and we try to open up.

And sometimes, when we are feeling very fragile we may start to cry and that may feel terrifying or humiliating. We might be afraid that our therapist is disgusted by our tears or is anxious for us to stop.

So I thought I would tell you what it’s like for a therapist (at least this therapist) when clients cry so then you will know. And you can ask your therapist what it’s like for her so you can know that, too.

I used to worry before I had clients that I would cry, too, because I usually cry when other people do but it turns out that the boundaries of our relationship protect me from this. That’s not to say that I don’t sometimes get a lump in my throat or have to quickly blink back tears before I catch myself but when my clients are crying, I’m very aware that I can’t let myself have the luxury of falling in with them. I feel both expansive — like I’m making way so there is room for all of the tears — and small — because I’m humbled by their vulnerability. I know that a big part of my job is being strong enough to stay exactly where I am and to allow my client to have her whole entire feeling without needing to share it with me or protect me from it or even to protect the feeling from me.

  • I do not judge her.
  • I do not feel annoyed.
  • I do not feel uncomfortable and wish she would stop.
  • I do not think she looks ugly or silly or weak.

I do trust her and I trust that crying is what she needs right then. I am a great believer in the power of crying to make us feel better. (I listened to this song a lot as a child.)

The counseling office is sacred space and part of what makes it sacred is that it’s a safe place for shedding tears.

Does my therapist care about me?

heartWhen I was in my late teens I began seeing a counselor because I was depressed. I was taking a full load of undergrad classes at OSU and working 40 hours a week and living by myself without roommates or family for the first time ever. My weekly visits to Barbara (my therapist) quickly became the center of my schedule. I’d drag myself to work and school, grind my way through my day, all the while focused on that bright spot, once a week, when I would sit in her office and feel safe.

I loved Barbara even when I didn’t love therapy, which was hard and often painful. I didn’t always leave her office feeling better. There were days I left feeling raw and fragile, my face swollen with tears. I started scheduling my work so I had the day off on therapy days so I could come home, curl up in bed and sleep away my emotional exhaustion. I could feel myself growing stronger and straighter but it was hard going.

I think I saw Barbara for about a year, maybe a little more, maybe a little less. I saw her weekly and then I saw her every other week and then we agreed I didn’t need to see her anymore at all. But for the time I was in her care, I felt very dependent on her and I wondered how it was for her because she may have been the person I centered my weeks around but I was just a client on her schedule.

I wanted her to call me up to have coffee. I wanted her to like me best of all of her clients. I wanted her to lean in one day and whisper, “My sessions with you are my favorite!” And I was free to want that as much as I liked because I knew it would never happen. It was a little like Lisa Simpson’s copies of Non-Threatening Boys Magazine; a celebrity crush, all safe and worry-free. I knew I could tell her anything and she’d have to like me — or at least pretend to like me — because it was her job.

But I always wondered if she cared about me for myself and not just as a name in her appointment book.

Now I know because I have my own appointment book (well, iCal calendar — same difference) and I can tell you that yes indeed, Barbara cared about me and your therapist cares about you. But we care within the boundaries our profession sets for us and those boundaries are what allow us to serve you. It’s not like caring for a friend or family member because it has specific limits and in other ways it is limitless. The space we hold together in the counseling relationship is full of unconditional positive regard (loving acceptance of all you are), which is harder to maintain in real life relationships. In that way the counseling relationship is boundless. On the other hand, I would never call a client up and say, “I’ve been thinking of you; let’s have coffee on Thursday.”

I remember when my son was very small and I heard about a preschool teacher who made space in her evenings to think about every single one of her students for a moment, hold the thought of each child close and then let it go. This is a little bit like how it is with clients. Before work, I review my schedule and mentally and emotionally prepare for the specific clients I will see that day. Each night, before I leave my office, I review them (usually as I write up case notes) and then on the way home, I give myself permission to stop thinking about them by the time I arrive home. This is because it’s easy to worry about a client going through a particularly tough time and worrying does neither of us any good. When I do catch myself feeling anxious about a specific client, I take a page from the preschool teacher and give myself permission to sit with my thoughts for a discrete time. This helps me come to my sessions fresh and focused instead of wrung out and worried.

So this love and caring I have for my clients — and that Barbara had for me — is not the love and caring I fantasized about when I was in therapy (there are no intimate coffees, there were no confessions of favoritism from Barbara) but it is good and solid and dependable.

Boundaries in counseling

brightcushions-insideLast week I said that I wanted to write about how the boundaries in counseling make the therapeutic relationship possible and so here I am! Writing about it!

The first time I really got the value of those boundaries was when I was driving away from a particularly tough session with a particularly tough client who also happened to be one of my very first clients. Without going into specifics that would compromise confidentiality, I will tell you that this was a client who seemed to have a black cloud of gloom and disaster following her. It always seemed like if a rotten thing could happen to her, it would. Some of this was of her own making but some of it was simply bad luck.

It made me miss being a case manager because as a case manager I’d have clear directives for her. We would be working a program together and I’d be bossing her around a little bit. I’d also have bus tickets and other program directors on speed dial to hook her up with other agencies (there’s an insider thing to case management that doesn’t seem to exist in community mental health agency work unless there’s a case management program there, too; like I can’t get a client free furniture but as a case manager in Portland I had access to those kinds of programs).

But I wasn’t her case manager (she had case managers), I was her counselor. And as her counselor I felt so helpless because I’d see her and she had so many challenges and I couldn’t do much but listen. I would meet with her and pay attention and help her make decisions and help her consider her options and help her process her emotions and I gave her all the unconditional positive regard I had at my disposal but it didn’t always feel like enough. I sure missed being able to hand over those bus tickets.

Unconditional positive regard is at the heart of counseling. When I am with a client, I am with them. I’m listening hard. I’m loving their humanity no matter what they’re saying. I’m seeing the human being that they are and I am accepting who they are even as I’m trying to help them to be their better selves.

So back to my tough session with my tough client.

I was driving away and I was thinking about something she’d said to me. We were talking about a pretty big barrier she was facing and I was itching to be the person in her life to be able to give her bus tickets and referrals and feeling pretty damn helpless to be just sitting there listening. I was having to work hard to not get lost in my feelings and instead stay there with her, present in her struggle, remembering that it was her struggle and not mine to fix. And she said, “This hour when we meet, it’s special to me because it’s the only time that’s all mine, all about me. It makes it so I can get through the rest of the week.”

That really brought home to me the value in “just” listening.

As I drove away I was thinking about how having nothing but my therapeutic self to give her — because counselors ethically can’t do the things case managers do. Ethically, counselors need to be very very very careful about handing out transportation or free furniture. Sure, we can give referrals to programs that do these things and there are times that stretching beyond ethical guidelines on gift giving is appropriate. But with this particular client, it was clear to me that any impetus I had to go beyond those limits would be about me and my fervent wish that her life be better and my feelings of helplessness in the face of her struggle.

I realized, too, that unlike the other helping people in her life (of which there were many), I was the only one who wasn’t asking her to do things. Well, that’s not entirely true — I did ask her to keep her appointments or at least call to cancel. And I did ask her talk to me. But these things happened more or less on her terms. She made the appointments at her convenience (within the bounds of my schedule). She talked about the things she most needed and wanted to talk about. We had a dialogue; I didn’t lecture and I didn’t make demands. She wrote her own treatment goals and we worked towards the things that mattered most to her with the context of her beliefs and values.

Because the boundaries of counseling dictated our relationship — that I not give her bus tickets, that I see her at this prescribed time in this prescribed way — I was able to fully be there with her.

If I had been her case manager I couldn’t have been with her as freely. Case management is all about moving someone through a case plan.  I also would have had to answer to the limits of our funding sources, which dictate which people a program can serve and how that program may serve them.

If I’d been her friend, I surely would have become fed up with the way her own decisions made her bad luck worse.

But as her counselor, I only had to be with her.

Our counseling relationship ended sooner than either of us would have liked due to some practicalities in her own situation but in the time we saw each other I did see real change in her attitude toward herself and towards her circumstances. Which is what cemented my faith in the value of the therapeutic relationship. Even if it doesn’t come with bus tickets.

Loneliness begets loneliness

Crisis Pregnancy CounselingI was reading this post by Gretchen Rubin, author of The Happiness Project, about loneliness and how feeling lonely makes us more negative, less likely to engage with other people, and altogether less likeable. We become “more aggressive, more self-defeating or self-destructive, less cooperative and helpful, and less prone simply to do the hard work of thinking clearly.” (This last bit is a quote from the book Gretchen was referencing in her post, Loneliness: Human Nature and the Need for Social Connection.)

I remember that when I was going through secondary infertility that I was very sad and that this sadness made me very lonely. Going through a personal crisis is like living in a bubble. You can see the people outside and you can hear them, but there’s a barrier between you and everyone else. People’s voices seemed to be coming from a long distance away, someplace where there was happiness and sunshine but I was living in this muted bubble where I could see the sun but not feel it’s warmth. I felt self-conscious in my sadness and found myself withdrawing from friends and family.

This is why I sought counseling. I knew I was in danger of isolating myself in a way that would not be good for me or my son. I could show up for things, sure, but the hard work of being present with other people felt beyond me.

Some people tell me that they are uncomfortable with counseling because it feels weird to pay someone to talk with you. But for me, there was safety in knowing that she could not reject me. The structure of our relationship — that I would hand her a check at the beginning and get 50-minutes of her time — was reassuring. I could be my worst self, my most selfish self, and she would still listen. I could be vulnerable and sad and she wouldn’t try to change the subject. I could ask her to lead the conversation when I was too exhausted by sadness to carry my end and she would.

That safety, that space we built together, helped heal some of my loneliness so I could be with my friends again. And even though I was paying for her time, I know she genuinely cared for me. I know this because I genuinely care for my clients.

I want to write more about that, too, how the boundaries of therapy is what makes the therapeutic relationship possible. Stay tuned for that, same bat time, same bat channel.

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