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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.

Play therapy looks like playing

play therapyUsually I let my kid-clients decide whether or not they want their parents to come into their play therapy sessions with them. (Some situations require parents be an active participant but most don’t.) The littlest children always want a parent to sit in the room, which is absolutely fine.  The kids and I play together and the parents watch or read a book or play on their smart phones.

I know that sometimes parents are sitting there watching us have a tea party or race cars or build with blocks and thinking, “I drove all this way for this? Took time out of the day, got the other kids childcare, took time off of work, took my kid out of school for this?” Because play therapy looks an awful lot like playing.

I try to head this off by explaining how play therapy works at the intake session but it doesn’t always sink in. And then we’re all in the office together and their child is playing and I’m watching (because I don’t play unless I get invited to play — my job is facilitation and observation) and … well, I’m not surprised when the question comes up, “What exactly are you doing anyway? And how is it helping?”

What I tell parents is that talk therapy is facilitated exploration through discussion and play therapy is facilitated exploration through play. Play is how kids communicate.

What makes the play therapy space special are the same things that make the talk therapy space special:

  • Unconditional positive regard (I accept you, I appreciate you, I see the good in you no matter what you do or say);
  • Safety (with rare exception what you share is private and stays in that room);
  • Concentrated focus (I am paying sharp attention to what you do/say and trying to both understand you better and help you understand yourself better);
  • A commitment to helping you move forward (I am actively looking for ways to help you grow through your experience);
  • A particular kind of loaded environment (comfy chairs, quiet, tissues at the ready and specific toys that encourage sharing).

Unlike most adults and bigger kids who can learn through give and take discussion, young children lack the insight and the vocabulary that allows them to discuss their experiences and feelings. Through play they are able to share what is causing them concern and work through it.

Many of the children who come see me play the same game over and over, trying to make sense of something so they can move forward. Just as talking something out can help, playing something out can help, too.

A common example is a child who heads straight to doctor’s kit every session because she’s working out her feelings about her last well-child visit. Having an understanding witness who gives voice (through her unbiased observation) to the story helps the child take control of her narrative.

Custody decisions and scope of practice

divorce-insideRecently I’ve talked to folks who are confused about what counselors can talk about when it comes to helping courts make custody decisions and I wanted to explain what we can and can’t say.

In general, therapists don’t make custody recommendations for ongoing clients, period.

A child custody evaluation is a very specific service that requires very specific training and it’s not the kind of thing a therapist could do for ongoing clients. Most of the people who do them are psychologists (although social workers and counselors are able to do the work as well).

Those of us who are regular old therapists don’t do custody evaluations and we definitely do not do them for current clients.

If I’m seeing a child or a parent for therapy I’ve entered a confidential, goal-oriented relationship that necessarily carries some bias. If I’m seeing a client who is having friction with a spouse I will only have access to her version of events even if I have a session or two with her partner. A couple of sessions with one partner in the context of a therapeutic relationship with the other isn’t going to do much to off-set any bias I carry. Obviously I cannot then say whether or not she would make the best parent.

Likewise if I’m seeing the children I’m not going to be able to look at the parents objectively because in a treatment-focused counseling relationship with a child I’m joining the family system and working with the members to change the system. Even if the child is my primary client, when I work with younger kids I am also working with the parents.

When I’m working with teens I have less parental contact — parents rarely join us for a session — but the issues of bias are still relevant.

So you can see why stepping outside of that therapist role and becoming an objective evaluator would be impossible; there’s no way I could get the distance necessary to see the family without prejudice. Sure, I might have an opinion but it’s not ethical or appropriate for me to share that opinion in a court of law.

Therapists are often asked to testify in custody cases but what we can ethically say is limited. Per Ohio law (that’s a link to a pdf) we absolutely should not make custody recommendations even when asked point blank by a judge. We can only testify to facts such as:

  • How often the client(s) came to treatment;
  • Whether or not the client(s) completed the treatment plan;
  • Which parent brought the child(ren) to treatment or attended sessions.

Basically the kinds of facts that can be corroborated.

According to a recent training I attended led by legal counsel for the Ohio Counselor, Social Work and Marriage & Family Therapist Board, a whole bunch of us are getting in trouble for misunderstanding our scope of practice when it comes to custody issues. Part of that is that we get nervous on the stand and maybe say more than we ought to and part of it is that some of us just don’t know better, which is why it’s a good idea for us to get our own legal representation should we get a subpoena. That way we understand what we can and can’t ethically say when called to testify.

Whether or not we must disclose information about a client without his or her permission — such as the contents of our sessions — depends on what the court says. But it’s important to know that lawyers can subpoena therapy case notes for a divorce case. While a therapist can and should fight to protect a client’s confidentiality, her hands may be tied legally. Therapists should make sure clients understand the limits of confidentiality during intake.

With kids, confidentiality belongs to the parents. Parents have a right to their children’s clinical case notes because they have rights to all of their medical records. When a divorce is happening this gets way more complicated. As that link shares, which parent has the right to the child’s case notes will depend on who has legal say over the child’s medical decisions.

If you have questions about your rights or your child’s rights when it comes to divorce and confidentiality, talk to the counselor and talk to a lawyer. But do know that you can’t ask your or your child’s counselor to recommend that you get custody of your children.

It’s a basic human right

Because I am easily astonished (and live in an adoption world populated by you nice, reasonable, progressive people), I can’t believe that open adoption records are still controversial.
States urged to open adoption records – CNN.com

In New Jersey, where a long-running campaign to pass an open-records bill was derailed again this year, the opposition includes New Jersey Right to Life and the New Jersey Catholic Conference. They argue that eliminating the prospect of confidentiality might prompt a pregnant single woman to choose abortion rather than adoption. Marlene Lao-Collins of the Catholic Conference said she knew of no data supporting the concerns about abortions, “but even if it just happened once, that would be one too many.”

Nationwide, one of the major foes of open records is the National Council for Adoption, which represents many religiously affiliated adoption agencies. Its president, Thomas Atwood, says any reconnection between an adopted adult and a birthparent should be by mutual consent — which is the policy in most states.

“I empathize with anybody who feels the need to know their biological parents’ identity,” Atwood said. “But I don’t think the law should enable them to force themselves on someone who has personal reasons for wanting confidentiality.”

So wait — open records are a pro-life tactic??? They’re arguing that even one POSSIBLE embryo lost is enough to keep actual living, breathing people from their constitutional right to know their birth histories — it’s just ludicrous.

Want to read more about the history of closed adoption? Check out How Adoption Grew Secret and then support the rights of adoptees.

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